Healthcare Provider Details

I. General information

NPI: 1508868209
Provider Name (Legal Business Name): LDJ ENDODONTICS, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 04/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8632 W CLARA LN
PEORIA AZ
85382-1429
US

IV. Provider business mailing address

8632 W CLARA LN
PEORIA AZ
85382-1429
US

V. Phone/Fax

Practice location:
  • Phone: 623-878-6996
  • Fax:
Mailing address:
  • Phone: 623-878-6996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number2335
License Number StateAZ

VIII. Authorized Official

Name: DR. LAURENCE DOUGLAS JOHNS
Title or Position: PRESIDENT
Credential:
Phone: 623-878-6996