Healthcare Provider Details

I. General information

NPI: 1821369455
Provider Name (Legal Business Name): PDA HOLDCO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2012
Last Update Date: 02/07/2023
Certification Date: 02/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1457 W SOUTHERN AVE STE 18
MESA AZ
85202-4853
US

IV. Provider business mailing address

1701 E THOMAS RD SUITE #204
PHOENIX AZ
85016-7646
US

V. Phone/Fax

Practice location:
  • Phone: 480-610-2300
  • Fax: 480-833-0682
Mailing address:
  • Phone: 602-253-6600
  • Fax: 602-279-0821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberD5504
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DANIEL MORRISSEY
Title or Position: PRESIDENT
Credential:
Phone: 602-253-6600