Healthcare Provider Details

I. General information

NPI: 1972796605
Provider Name (Legal Business Name): KINDER PEDIATRIC DENTAL SPECIALIST, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2007
Last Update Date: 05/20/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 W. APACHE TRAIL
APACHE JUNCTION AZ
85120
US

IV. Provider business mailing address

11442 E BELLS VISITS DR
SCOTTSDALE AZ
85259
US

V. Phone/Fax

Practice location:
  • Phone: 480-288-5955
  • Fax: 480-288-4345
Mailing address:
  • Phone: 480-288-5955
  • Fax: 480-288-4345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number51010
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. EDWARD ESSER DOVE
Title or Position: MEMBER
Credential: DDS
Phone: 818-644-7124