Healthcare Provider Details

I. General information

NPI: 1265129852
Provider Name (Legal Business Name): STARLIGHT ORTHODONTICS & PEDIATRIC DENTISTRY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2023
Last Update Date: 07/25/2023
Certification Date: 04/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3440 W CACTUS RD STE 1
PHOENIX AZ
85029-2238
US

IV. Provider business mailing address

3440 W CACTUS RD STE 1
PHOENIX AZ
85029-2238
US

V. Phone/Fax

Practice location:
  • Phone: 623-688-3364
  • Fax:
Mailing address:
  • Phone: 623-688-3364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MR. ALBERT TAE
Title or Position: CEO
Credential:
Phone: 424-392-2715