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General NPI Number Information
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NPI Number | 1073895629
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Entity Type | Organization
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Legal Business Name | KIDIATRIC DENTISTRY, PLLC
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Dates
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Enumeration Date | 09/09/2011
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Last Update Date | 09/09/2011
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Provider Practice Location Address
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Address Line | 913 E WARNER RD
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City | GILBERT
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State | AZ
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Zip | 85296-3078
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Country | US
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Telephone | 602-418-1599
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Fax |
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Provider Business Mailing Address
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Address Line | 913 E WARNER RD
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City | GILBERT
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State | AZ
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Zip | 85296-3078
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Country | US
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Telephone | 602-418-1599
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Fax |
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Authorized Official
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Title or Position | PEDIATRIC DENTIST/OWNER
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Name | DR. WALTER VILLANUEVA
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Credential | D.D.S.
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Telephone | 602-418-1592
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | D7782
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License Number State | AZ
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