Healthcare Provider Details

I. General information

NPI: 1760036644
Provider Name (Legal Business Name): HDP AFFINITY DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2019
Last Update Date: 11/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21321 E OCOTILLO RD STE 130
QUEEN CREEK AZ
85142-5995
US

IV. Provider business mailing address

2403 LACY LN
CARROLLTON TX
75006-6514
US

V. Phone/Fax

Practice location:
  • Phone: 480-882-2300
  • Fax:
Mailing address:
  • Phone: 972-869-3789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: FAITH GASKINS
Title or Position: DIRECTOR OF CREDENTIALING
Credential:
Phone: 972-869-3789