Provider Demographics
NPI:1174771612
Name:KATSUR DENTAL OF ARIZONA, INC.
Entity type:Organization
Organization Name:KATSUR DENTAL OF ARIZONA, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDINER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-772-5124
Mailing Address - Street 1:926 GREAT POND DR
Mailing Address - Street 2:SUITE 5000
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-7244
Mailing Address - Country:US
Mailing Address - Phone:407-772-5124
Mailing Address - Fax:407-788-3572
Practice Address - Street 1:105 N LITCHFIELD RD
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-1617
Practice Address - Country:US
Practice Address - Phone:623-932-3200
Practice Address - Fax:623-932-3222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-08
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ57951223G0001X
AZ52161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ565806OtherSANTORO AHCCCS#
AZ294311OtherLOAN KIM DAO AHCCCS#
AZ197645OtherONET AHCCCS#
AZ506058OtherTURNER AHCCCS#
AZ368780OtherGROUP AHCCCS#
AZ561921OtherWHATCOTT AHCCCS#
AZ774457OtherSKAALEN AHCCCS#