Healthcare Provider Details

I. General information

NPI: 1447976261
Provider Name (Legal Business Name): SDCAZ LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2022
Last Update Date: 01/07/2026
Certification Date: 01/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 E BASELINE RD
PHOENIX AZ
85042-6554
US

IV. Provider business mailing address

524 E BASELINE RD
PHOENIX AZ
85042-6554
US

V. Phone/Fax

Practice location:
  • Phone: 480-725-0729
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: CASSANDRA WIETH
Title or Position: DIRECTOR OF PAYOR RELATIONS
Credential:
Phone: 623-267-8121