Healthcare Provider Details

I. General information

NPI: 1184500852
Provider Name (Legal Business Name): AZ SDS III LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2025
Last Update Date: 08/15/2025
Certification Date: 08/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4232 E CHANDLER BLVD STE 10
PHOENIX AZ
85048-8879
US

IV. Provider business mailing address

1610 54TH AVE N STE 205
NASHVILLE TN
37209-1442
US

V. Phone/Fax

Practice location:
  • Phone: 480-759-1119
  • Fax:
Mailing address:
  • Phone: 504-638-0303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: CHARLOTTE DASCH
Title or Position: SR DIRECTOR OF CREDENTIALING
Credential:
Phone: 504-638-0303