Healthcare Provider Details

I. General information

NPI: 1316113715
Provider Name (Legal Business Name): TOOTH CASTLE PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2008
Last Update Date: 08/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2316 W BETHANY HOME RD SUITE 110
PHOENIX AZ
85015-1850
US

IV. Provider business mailing address

PO BOX 45359
PHOENIX AZ
85064-5359
US

V. Phone/Fax

Practice location:
  • Phone: 602-841-4400
  • Fax: 601-841-4404
Mailing address:
  • Phone: 602-841-4400
  • Fax: 602-841-4404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. MARIA ANGELES FUENTES
Title or Position: OWNER
Credential: DDS
Phone: 602-841-4400