Healthcare Provider Details

I. General information

NPI: 1154540367
Provider Name (Legal Business Name): DENTISTRY FOR CHILDREN PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 E SOUTHERN AVE STE 12
MESA AZ
85204-5137
US

IV. Provider business mailing address

1245 E SOUTHERN AVE STE 12
MESA AZ
85204-5137
US

V. Phone/Fax

Practice location:
  • Phone: 480-610-6544
  • Fax: 480-633-0670
Mailing address:
  • Phone: 480-610-6544
  • Fax: 480-633-0670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5678
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number5589
License Number StateAZ

VIII. Authorized Official

Name: SHARRON KEENE
Title or Position: OFFICE SUPERVISOR
Credential:
Phone: 480-610-6544