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General NPI Number Information
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NPI Number | 1588207591
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Entity Type | Organization
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Legal Business Name | ELLIOT ROAD DENTAL PLLC
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Dates
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Enumeration Date | 10/22/2019
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Last Update Date | 10/31/2019
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Provider Practice Location Address
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Address Line | 2010 E ELLIOT RD STE 105
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City | TEMPE
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State | AZ
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Zip | 85284-1790
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Country | US
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Telephone | 480-839-7996
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Fax |
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Provider Business Mailing Address
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Address Line | 2010 E ELLIOT RD STE 105
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City | TEMPE
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State | AZ
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Zip | 85284-1790
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Country | US
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Telephone | 480-839-7996
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Fax |
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Authorized Official
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Title or Position | DIRECTOR OF CREDENTIALING
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Name | FAITH GASKINS
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Credential |
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Telephone | 972-869-3789
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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 |
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License Number State |
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