Provider Demographics
NPI:1063383115
Name:GREAT DENTISTRY PLLC
Entity type:Organization
Organization Name:GREAT DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:EDGARDO
Authorized Official - Middle Name:NICOLAS
Authorized Official - Last Name:TIMPANARO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:602-323-6862
Mailing Address - Street 1:6496 E BROMBIL ST
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-3837
Mailing Address - Country:US
Mailing Address - Phone:602-323-6862
Mailing Address - Fax:
Practice Address - Street 1:430 W FINNIE FLAT RD
Practice Address - Street 2:
Practice Address - City:CAMP VERDE
Practice Address - State:AZ
Practice Address - Zip Code:86322-7362
Practice Address - Country:US
Practice Address - Phone:928-567-3799
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-09-12
Last Update Date:2025-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty