Healthcare Provider Details

I. General information

NPI: 1619444833
Provider Name (Legal Business Name): WEST VALLEY ENDODONTICS AND ORAL SURGERY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2018
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14122 W MCDOWELL RD STE 201
GOODYEAR AZ
85395-2505
US

IV. Provider business mailing address

14122 W MCDOWELL RD STE 201
GOODYEAR AZ
85395-2505
US

V. Phone/Fax

Practice location:
  • Phone: 623-444-4521
  • Fax: 623-444-8304
Mailing address:
  • Phone: 623-444-4521
  • Fax: 623-444-8304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: MRS. RANDEE L JACKSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 623-444-4521