Provider Demographics
NPI:1871058891
Name:DENTAL AND BRACES MARYVALE LLC
Entity type:Organization
Organization Name:DENTAL AND BRACES MARYVALE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LIZ
Authorized Official - Middle Name:
Authorized Official - Last Name:RAMOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-714-8203
Mailing Address - Street 1:1515 N GILBERT RD STE 107-131
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2318
Mailing Address - Country:US
Mailing Address - Phone:602-714-8203
Mailing Address - Fax:
Practice Address - Street 1:6702 W CAMELBACK RD STE 100
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85303-6324
Practice Address - Country:US
Practice Address - Phone:602-635-7450
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-04
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
12740016OtherGENERAL DENTAL OFFICE