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General NPI Number Information
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NPI Number | 1043938368
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Entity Type | Organization
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Legal Business Name | SOH OF ARIZONA SPECIALTY LLC
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Dates
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Enumeration Date | 08/22/2022
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Last Update Date | 04/20/2023
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Provider Practice Location Address
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Address Line | 16620 N 40TH ST STE A1
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City | PHOENIX
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State | AZ
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Zip | 85032-3349
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Country | US
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Telephone | 602-842-6988
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Fax |
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Provider Business Mailing Address
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Address Line | 1422 ELBRIDGE PAYNE RD STE 240
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City | CHESTERFIELD
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State | MO
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Zip | 63017-8544
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Country | US
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Telephone | 636-362-4986
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING SPECIALIST
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Name | ASHLY KRISTINE SUNSHINE
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Credential |
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Telephone | 314-413-2803
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number |
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License Number State |
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