Healthcare Provider Details

I. General information

NPI: 1235641937
Provider Name (Legal Business Name): KETHCART SLEEP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2017
Last Update Date: 07/13/2020
Certification Date: 07/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1277 E MISSOURI AVE STE 102
PHOENIX AZ
85014-2916
US

IV. Provider business mailing address

1277 E MISSOURI AVE STE 102
PHOENIX AZ
85014-2916
US

V. Phone/Fax

Practice location:
  • Phone: 602-615-8516
  • Fax: 602-883-7252
Mailing address:
  • Phone: 602-615-8516
  • Fax: 602-883-7252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberD6695
License Number StateAZ

VIII. Authorized Official

Name: DR. STEPHANIE WAGNER KETHCART
Title or Position: MANAGAING MEMBER/DENTIST
Credential: DDS
Phone: 602-615-8516