=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427414341
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILT& ESTHETIC DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2016
-----------------------------------------------------
Last Update Date | 01/07/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6666 W PEORIA AVE
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85302-7014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-878-6000
-----------------------------------------------------
Fax | 623-773-2230
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6666 W PEORIA AVE
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85302-7014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-878-6000
-----------------------------------------------------
Fax | 623-773-2230
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL DENTIST
-----------------------------------------------------
Name | DR. NEDA DELAVARI
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 623-878-6000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 8667
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------