Healthcare Provider Details

I. General information

NPI: 1215281688
Provider Name (Legal Business Name): FIESTA KIDTASTIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2012
Last Update Date: 12/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1303 S LONGMORE STE 1
MESA AZ
85202-9607
US

IV. Provider business mailing address

4704 E SOUTHERN AVE
MESA AZ
85206-2737
US

V. Phone/Fax

Practice location:
  • Phone: 480-648-4037
  • Fax: 480-696-5505
Mailing address:
  • Phone: 480-648-4037
  • Fax: 480-696-5505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MS. JAIME JOHNSON
Title or Position: CONTROLLER
Credential:
Phone: 480-648-4037