Healthcare Provider Details

I. General information

NPI: 1053132084
Provider Name (Legal Business Name): TOOTH CLUB FOR KIDS PHOENIX
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2024
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7777 N 43RD AVE
PHOENIX AZ
85051-5712
US

IV. Provider business mailing address

4901 W BELL RD STE 100
GLENDALE AZ
85308-3414
US

V. Phone/Fax

Practice location:
  • Phone: 602-888-7844
  • Fax: 602-843-1276
Mailing address:
  • Phone: 602-843-1275
  • Fax: 602-843-1276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. KIMBERLIE APRIL STUBBS
Title or Position: OFFICE MANAGER
Credential:
Phone: 602-843-1275