=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134833502
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TOTALLY KIDS DENTAL P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2023
-----------------------------------------------------
Last Update Date | 01/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3825 N 75TH AVE STE 101&102
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85033-3700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-610-5088
-----------------------------------------------------
Fax | 602-806-8910
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3825 N 75TH AVE STE 101&102
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85033-3700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-610-5088
-----------------------------------------------------
Fax | 602-806-8910
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | RYAN B. BAKER
-----------------------------------------------------
Credential | DMD, MPH, MS
-----------------------------------------------------
Telephone | 602-610-5088
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------