=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174771612
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KATSUR DENTAL OF ARIZONA, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2008
-----------------------------------------------------
Last Update Date | 11/12/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 105 N LITCHFIELD RD
-----------------------------------------------------
City | GOODYEAR
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85338-1617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-932-3200
-----------------------------------------------------
Fax | 623-932-3222
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 926 GREAT POND DR SUITE 5000
-----------------------------------------------------
City | ALTAMONTE SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32714-7244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-772-5124
-----------------------------------------------------
Fax | 407-788-3572
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING COORDINATOR
-----------------------------------------------------
Name | TERRI GARDINER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 407-772-5124
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 5795
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 5216
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------