Healthcare Provider Details

I. General information

NPI: 1518366111
Provider Name (Legal Business Name): EAST VALLEY DENTAL ANESTHESIA, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2014
Last Update Date: 08/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 S HIGLEY RD SUITE 103
GILBERT AZ
85296-1166
US

IV. Provider business mailing address

67 S HIGLEY RD SUITE 103
GILBERT AZ
85296-1166
US

V. Phone/Fax

Practice location:
  • Phone: 480-518-5502
  • Fax: 480-219-9234
Mailing address:
  • Phone: 480-518-5502
  • Fax: 480-219-9234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number5604
License Number StateAZ

VIII. Authorized Official

Name: DR. MARVIN TODD CHRISTENSEN
Title or Position: OWNER/OPERATOR
Credential: DMD
Phone: 480-518-5502