Healthcare Provider Details

I. General information

NPI: 1619719036
Provider Name (Legal Business Name): AZ SDS II LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2024
Last Update Date: 06/07/2024
Certification Date: 06/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3409 N 56TH ST STE C
PHOENIX AZ
85018-6150
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 480-748-4264
  • Fax:
Mailing address:
  • Phone: 615-678-0759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: CHARLOTTE DASCH
Title or Position: DIRECTOR OF CRED AND PR
Credential:
Phone: 504-638-0303