=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912121930
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STEVEN K. INGERSOLL DDS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10211 N 32ND ST STE A1
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85028-3841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-953-1744
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10211 N 32ND ST STE A1
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85028-3841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-953-1744
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. STEVEN K INGERSOLL
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 602-953-1744
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | D2811
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------