Healthcare Provider Details

I. General information

NPI: 1568523363
Provider Name (Legal Business Name): STRAIGHT LINE ORTHODONTICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14640 N TATUM BLVD #5
PHOENIX AZ
85032-4824
US

IV. Provider business mailing address

14640 N TATUM BLVD #5
PHOENIX AZ
85032-4824
US

V. Phone/Fax

Practice location:
  • Phone: 602-992-7182
  • Fax: 602-992-0157
Mailing address:
  • Phone: 602-992-7182
  • Fax: 602-992-0157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number1653
License Number StateAZ

VIII. Authorized Official

Name: MS. PAULA M WILSON
Title or Position: OWNER
Credential:
Phone: 602-992-7182