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General NPI Number Information
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NPI Number | 1265896468
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Entity Type | Organization
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Legal Business Name | DESERT VILLA DENTAL LLC
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Dates
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Enumeration Date | 04/13/2016
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Last Update Date | 04/13/2016
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Provider Practice Location Address
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Address Line | 1055 N LA CANADA DR STE 109
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City | GREEN VALLEY
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State | AZ
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Zip | 85614-3700
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Country | US
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Telephone | 520-399-2700
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Fax | 520-399-4001
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Provider Business Mailing Address
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Address Line | 1055 N LA CANADA DR STE 109
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City | GREEN VALLEY
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State | AZ
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Zip | 85614-3700
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Country | US
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Telephone | 520-399-2700
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Fax | 520-399-4001
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Authorized Official
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Title or Position | OWNER
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Name | DR. WA N CHAO
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Credential | DDS
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Telephone | 520-399-2700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D05986
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License Number State | AZ
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