=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649775842
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AGAVE FAMILY DENTAL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2018
-----------------------------------------------------
Last Update Date | 03/28/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 855 E WARNER RD STE 104
-----------------------------------------------------
City | CHANDLER
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85225-0998
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-389-2452
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 855 E WARNER RD STE 104
-----------------------------------------------------
City | CHANDLER
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85225-0998
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-389-2452
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGER
-----------------------------------------------------
Name | DONNA PERKINS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 480-830-0262
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------