=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548307424
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DESERT VISTA DENTAL WEST PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2007
-----------------------------------------------------
Last Update Date | 10/15/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1646 N LITCHFIELD RD SUITE 125
-----------------------------------------------------
City | GOODYEAR
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85395-1203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-935-2755
-----------------------------------------------------
Fax | 623-935-0265
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1646 N LITCHFIELD RD SUITE 125
-----------------------------------------------------
City | GOODYEAR
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85395-1203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-935-2755
-----------------------------------------------------
Fax | 623-935-0265
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MS. STACY K CORDOVA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 623-935-2755
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------