Healthcare Provider Details

I. General information

NPI: 1366281149
Provider Name (Legal Business Name): BASELINE ROAD DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2024
Last Update Date: 05/22/2024
Certification Date: 05/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3130 E BASELINE RD 105/106
MESA AZ
85204
US

IV. Provider business mailing address

3130 E BASELINE RD 105/106
MESA AZ
85204
US

V. Phone/Fax

Practice location:
  • Phone: 480-701-6656
  • Fax: 480-452-1614
Mailing address:
  • Phone: 480-701-6656
  • Fax: 480-452-1614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: JENNY GARCIA ROCHA
Title or Position: SR TEAM LEAD
Credential:
Phone: 972-869-3789