Provider Demographics
NPI:1649481359
Name:ARIZONA DENTAL PROFESSIONALS, P.C.
Entity type:Organization
Organization Name:ARIZONA DENTAL PROFESSIONALS, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JASMINE
Authorized Official - Middle Name:
Authorized Official - Last Name:REARDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8330
Mailing Address - Street 1:2805 W CAREFREE HIGHWAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-8847
Mailing Address - Country:US
Mailing Address - Phone:623-492-0300
Mailing Address - Fax:623-492-0312
Practice Address - Street 1:2805 W CAREFREE HIGHWAY
Practice Address - Street 2:SUITE 101
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85086-8847
Practice Address - Country:US
Practice Address - Phone:623-492-0300
Practice Address - Fax:623-492-0312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ59751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty