Provider Demographics
NPI:1366281149
Name:BASELINE ROAD DENTAL LLC
Entity type:Organization
Organization Name:BASELINE ROAD DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR TEAM LEAD
Authorized Official - Prefix:
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:GARCIA ROCHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-869-3789
Mailing Address - Street 1:3130 E BASELINE RD 105/106
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204
Mailing Address - Country:US
Mailing Address - Phone:480-701-6656
Mailing Address - Fax:480-452-1614
Practice Address - Street 1:3130 E BASELINE RD 105/106
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204
Practice Address - Country:US
Practice Address - Phone:480-701-6656
Practice Address - Fax:480-452-1614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-22
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty