Healthcare Provider Details

I. General information

NPI: 1154622249
Provider Name (Legal Business Name): SOUTHWEST DENTAL PROFESSIONALS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2010
Last Update Date: 11/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 W ANGUS RD
QUEEN CREEK AZ
85143-4989
US

IV. Provider business mailing address

316 W ANGUS RD
QUEEN CREEK AZ
85143-4989
US

V. Phone/Fax

Practice location:
  • Phone: 480-390-2060
  • Fax:
Mailing address:
  • Phone: 480-390-2060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD07819
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD08719
License Number StateAZ

VIII. Authorized Official

Name: DR. LAWRENCE G GROOP
Title or Position: OWNER/PRES
Credential: DMD
Phone: 480-664-1449