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General NPI Number Information
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NPI Number | 1396586400
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Entity Type | Organization
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Legal Business Name | DENTAL DEPOT ORTHODONTICS 83RD AND UNION HILLS, PLLC
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Dates
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Enumeration Date | 06/03/2024
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Last Update Date | 06/03/2024
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Provider Practice Location Address
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Address Line | 18855 N 83RD AVE STE B
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City | PEORIA
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State | AZ
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Zip | 85382-2806
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Country | US
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Telephone | 623-352-0195
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Fax |
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Provider Business Mailing Address
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Address Line | 2828 NW 30TH ST
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City | OKLAHOMA CITY
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State | OK
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Zip | 73112-7404
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Country | US
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Telephone | 623-267-4129
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Fax |
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Authorized Official
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Title or Position | DIRECTOR OF PROVIDER RELATIONS
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Name | GAYLON ZISSA
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Credential |
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Telephone | 405-945-8941
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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