Healthcare Provider Details

I. General information

NPI: 1710359658
Provider Name (Legal Business Name): SV GILBERT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2015
Last Update Date: 10/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3592 S ATHERTON BLVD SUITE 107
GILBERT AZ
85297-7443
US

IV. Provider business mailing address

4435 E HOLMES AVE
MESA AZ
85206-3372
US

V. Phone/Fax

Practice location:
  • Phone: 480-889-1877
  • Fax: 480-889-1876
Mailing address:
  • Phone: 480-889-9457
  • Fax: 480-696-5505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JOHN E BALLARD
Title or Position: CFO, CIO
Credential:
Phone: 480-889-9457