Healthcare Provider Details

I. General information

NPI: 1932531753
Provider Name (Legal Business Name): DEIDRA C DEXTER-HINE RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DEIDRA C DEXTER

II. Dates (important events)

Enumeration Date: 08/02/2013
Last Update Date: 08/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5131 E SOUTHERN AVE
MESA AZ
85206-2799
US

IV. Provider business mailing address

1919 E THOMAS RD BLDG 2108 SUITE 101
PHOENIX AZ
85016-7710
US

V. Phone/Fax

Practice location:
  • Phone: 480-833-5437
  • Fax: 480-833-9349
Mailing address:
  • Phone: 602-512-8029
  • Fax: 602-512-8161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number970698
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: