Healthcare Provider Details

I. General information

NPI: 1265734701
Provider Name (Legal Business Name): EAST VALLEY ENDODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2010
Last Update Date: 12/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18610 E RITTENHOUSE RD # A-104
QUEEN CREEK AZ
85142-4503
US

IV. Provider business mailing address

18610 E RITTENHOUSE RD # A-104
QUEEN CREEK AZ
85142-4503
US

V. Phone/Fax

Practice location:
  • Phone: 480-988-0020
  • Fax: 480-988-6208
Mailing address:
  • Phone: 480-988-0020
  • Fax: 480-988-6208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD4318
License Number StateAZ

VIII. Authorized Official

Name: DR. STEVEN L FROST
Title or Position: OWNER
Credential: D.D.S.
Phone: 480-988-0020