MEDICARE: KIDS INTEGRATIVE NORTERRA DENTISTRY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1619822194
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDS INTEGRATIVE NORTERRA DENTISTRY, LLC

Provider Business Mailing Address
First Line	:	1934 E CAMELBACK RD STE 110
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-4136
Country	:	US
Telephone Number	:	602-833-2564
Fax Number	:

Provider Business Practice Location Address
First Line	:	2460 W HAPPY VALLEY RD STE 1189
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85085-8511
Country	:	US
Telephone Number	:	602-833-2564
Fax Number	:

Authorized Official
Title or Position	:	CHIEF LEGAL OFFICER
Name	:	MR. BEN J HIMMELSTEIN
Credential	:	ESQ.
Telephone Number	:	480-229-7498

Provider Enumeration Date	:	03/02/2026
Last Update Date	:	03/02/2026

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