Healthcare Provider Details

I. General information

NPI: 1760188098
Provider Name (Legal Business Name): PDA HOLDINGS WEST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2023
Last Update Date: 02/07/2023
Certification Date: 02/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5109 W THOMAS RD STE 300
PHOENIX AZ
85031-3944
US

IV. Provider business mailing address

5109 W THOMAS RD STE 300
PHOENIX AZ
85031-3944
US

V. Phone/Fax

Practice location:
  • Phone: 602-472-3553
  • Fax: 602-687-9844
Mailing address:
  • Phone: 602-472-3553
  • Fax: 602-687-9844

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: JERAMY TARWATER
Title or Position: PRESIDENT
Credential:
Phone: 602-253-6600