Healthcare Provider Details

I. General information

NPI: 1205408622
Provider Name (Legal Business Name): IVY 2 DENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2021
Last Update Date: 07/14/2021
Certification Date: 07/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 E WETMORE RD STE 101
TUCSON AZ
85705-1700
US

IV. Provider business mailing address

23374 W YUMA RD STE 102
BUCKEYE AZ
85326-3120
US

V. Phone/Fax

Practice location:
  • Phone: 623-444-9999
  • Fax: 623-444-6745
Mailing address:
  • Phone: 623-444-9999
  • Fax: 623-444-6745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: UMAR M IMTIAZ
Title or Position: ASSOCIATE PROVIDER
Credential: DDS
Phone: 623-444-9999