Healthcare Provider Details

I. General information

NPI: 1902250368
Provider Name (Legal Business Name): ARIZONA SMILES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2016
Last Update Date: 04/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 N GILBERT RD SUITE Z
GILBERT AZ
85234-2328
US

IV. Provider business mailing address

1400 N GILBERT ROAD SUITE Z
GILBERT AZ
85234
US

V. Phone/Fax

Practice location:
  • Phone: 480-892-5089
  • Fax: 480-892-4236
Mailing address:
  • Phone: 480-892-5089
  • Fax: 480-892-4236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number StateAZ

VIII. Authorized Official

Name: DR. SAMUEL WALKER BOLLWINKEL
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 480-892-5089