Healthcare Provider Details

I. General information

NPI: 1134345937
Provider Name (Legal Business Name): PDA HOLDINGS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 02/07/2023
Certification Date: 02/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 E THOMAS RD #204
PHOENIX AZ
85016
US

IV. Provider business mailing address

1701 E THOMAS RD STE 204
PHOENIX AZ
85016-7675
US

V. Phone/Fax

Practice location:
  • Phone: 602-253-6600
  • Fax: 602-279-0821
Mailing address:
  • Phone: 602-253-6600
  • Fax: 602-279-0821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AMANDA J TRUJILLO
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 602-253-6600