Healthcare Provider Details

I. General information

NPI: 1619449550
Provider Name (Legal Business Name): THUNDERBIRD DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2018
Last Update Date: 09/14/2020
Certification Date: 09/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9160 N 43RD AVE
GLENDALE AZ
85302-3801
US

IV. Provider business mailing address

9160 N 43RD AVE
GLENDALE AZ
85302-3801
US

V. Phone/Fax

Practice location:
  • Phone: 623-931-9221
  • Fax: 623-937-4315
Mailing address:
  • Phone: 623-931-9221
  • Fax: 623-937-4315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. LETICIA ROJAS
Title or Position: MANAGER
Credential:
Phone: 623-931-9221