Provider Demographics
NPI:1679615587
Name:SUN WEST DENTAL III, LLC
Entity type:Organization
Organization Name:SUN WEST DENTAL III, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:DALTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-354-5800
Mailing Address - Street 1:4425 N. 24TH ST SUITE 100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016
Mailing Address - Country:US
Mailing Address - Phone:602-354-5800
Mailing Address - Fax:602-354-5860
Practice Address - Street 1:1842 E. BASELINE RD.
Practice Address - Street 2:#B2
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283
Practice Address - Country:US
Practice Address - Phone:480-831-8022
Practice Address - Fax:480-831-8023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD4013122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty