Healthcare Provider Details

I. General information

NPI: 1053753228
Provider Name (Legal Business Name): NORTH VALLEY ORTHODONTICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2013
Last Update Date: 07/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21050 N TATUM BLVD STE D202
PHOENIX AZ
85050-4260
US

IV. Provider business mailing address

21050 N TATUM BLVD STE D202
PHOENIX AZ
85050-4260
US

V. Phone/Fax

Practice location:
  • Phone: 480-419-2222
  • Fax: 480-419-9222
Mailing address:
  • Phone: 480-419-2222
  • Fax: 480-419-9222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD6818
License Number StateAZ

VIII. Authorized Official

Name: ALYSSA LEVIN
Title or Position: MANAGING MEMBER
Credential: DDS, MS
Phone: 480-419-2222