=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063637197
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROLLINS & PETERSEN ORTHODONTICS PLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6755 E SUPERSTITION SPRINGS BLVD STE 201
-----------------------------------------------------
City | MESA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-924-2880
-----------------------------------------------------
Fax | 480-924-5634
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6755 E SUPERSTITION SPRINGS BLVD STE 201
-----------------------------------------------------
City | MESA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-924-2880
-----------------------------------------------------
Fax | 480-924-5634
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | ARLON M PETERSEN
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 480-924-2880
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 4793
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 1961
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------