Healthcare Provider Details

I. General information

NPI: 1346501079
Provider Name (Legal Business Name): WESTERN DENTAL OF ARIZONA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2012
Last Update Date: 05/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1080 W ELLIOT RD
TEMPE AZ
85284-1111
US

IV. Provider business mailing address

530 S MAIN ST
ORANGE CA
92868-4525
US

V. Phone/Fax

Practice location:
  • Phone: 480-845-6625
  • Fax: 480-845-6634
Mailing address:
  • Phone: 714-480-3000
  • Fax: 714-571-6445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: SILVIA DIAZ
Title or Position: PPO COORDINATOR
Credential:
Phone: 714-480-3000