Healthcare Provider Details

I. General information

NPI: 1366988404
Provider Name (Legal Business Name): SOHO- SENIOR ORAL HEALTH OUTREACH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2017
Last Update Date: 01/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 N 44TH ST SUITE 102
PHOENIX AZ
85018-2782
US

IV. Provider business mailing address

4901 N 44TH ST SUITE 102
PHOENIX AZ
85018-2782
US

V. Phone/Fax

Practice location:
  • Phone: 480-779-0227
  • Fax:
Mailing address:
  • Phone: 480-779-0227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD08533
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberD08533
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberD08533
License Number StateAZ

VIII. Authorized Official

Name: DR. STEFANIE HOURANI
Title or Position: DIRECTOR
Credential: DDS
Phone: 402-650-0686