=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528605649
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENTISTS AT QUEEN CREEK, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2019
-----------------------------------------------------
Last Update Date | 12/09/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21295 S ELLSWORTH LOOP RD
-----------------------------------------------------
City | QUEEN CREEK
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85142-9866
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-445-9188
-----------------------------------------------------
Fax | 480-526-8177
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1046 WESTWOOD TRL
-----------------------------------------------------
City | ONEIDA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13421-4629
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-761-9837
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING MANAGER
-----------------------------------------------------
Name | BRITTANY EDDY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 713-869-4535
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------