Healthcare Provider Details

I. General information

NPI: 1487228961
Provider Name (Legal Business Name): PEPSQUAD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2021
Last Update Date: 05/18/2021
Certification Date: 05/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5215 E SOUTHERN AVE
MESA AZ
85206-2777
US

IV. Provider business mailing address

4309 W NOB HILL BLVD
YAKIMA WA
98908-3971
US

V. Phone/Fax

Practice location:
  • Phone: 509-823-4480
  • Fax: 509-823-4490
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code122400000X
TaxonomyDenturist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DEREK THOMPSON
Title or Position: OWNER
Credential:
Phone: 509-823-4480