Healthcare Provider Details

I. General information

NPI: 1386917839
Provider Name (Legal Business Name): COMMUNITY DENTAL PARTNERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2012
Last Update Date: 02/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21321 E OCOTILLO RD BLDG C STE.106
QUEEN CREEK AZ
85142-5996
US

IV. Provider business mailing address

3221 N 24TH ST STE. 23
PHOENIX AZ
85016-7358
US

V. Phone/Fax

Practice location:
  • Phone: 602-370-1511
  • Fax: 602-265-4007
Mailing address:
  • Phone: 602-370-1511
  • Fax: 602-265-4007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD5063
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD5110
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD1819
License Number StateAZ

VIII. Authorized Official

Name: MR. EOIN KIRBY
Title or Position: CREDENTIALING SUPERVISOR
Credential:
Phone: 602-370-1511