=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235596081
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHWEST GD DENTAL CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/25/2016
-----------------------------------------------------
Last Update Date | 01/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6601 S RURAL RD
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85283-3747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-730-1857
-----------------------------------------------------
Fax | 480-831-0702
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6601 S RURAL RD
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85283-3747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-730-1857
-----------------------------------------------------
Fax | 480-831-0702
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JON DELSNYDER
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 480-730-1857
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------