Provider Demographics
NPI:1437976701
Name:DICKERSON ORTHODONTICS LLC
Entity type:Organization
Organization Name:DICKERSON ORTHODONTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR CREDENTIALING 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 1:1200 W WARNER RD STE 1
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-2758
Mailing Address - Country:US
Mailing Address - Phone:480-963-2535
Mailing Address - Fax:
Practice Address - Street 1:1200 W WARNER RD STE 1
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-2758
Practice Address - Country:US
Practice Address - Phone:480-963-2535
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-26
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty