Healthcare Provider Details

I. General information

NPI: 1275687790
Provider Name (Legal Business Name): SOCIETY OF ST. VINCENT DE PAUL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 W WATKINS RD
PHOENIX AZ
85003-2830
US

IV. Provider business mailing address

420 W WATKINS RD
PHOENIX AZ
85003-2830
US

V. Phone/Fax

Practice location:
  • Phone: 602-261-6874
  • Fax: 602-261-6816
Mailing address:
  • Phone: 602-261-6874
  • Fax: 602-261-6816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberAZ2056
License Number StateAZ

VIII. Authorized Official

Name: DR. FLOYD KENNETH SNYDER
Title or Position: DENTAL CLINIC DIRECTOR
Credential: DMD
Phone: 602-261-6825