Provider Demographics
NPI:1942481718
Name:SUNDANCE MEDICAL ASSOCIATES PLLC
Entity type:Organization
Organization Name:SUNDANCE MEDICAL ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:SACKETT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:480-782-0609
Mailing Address - Street 1:633 E RAY RD STE 133
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-4206
Mailing Address - Country:US
Mailing Address - Phone:480-782-0609
Mailing Address - Fax:480-782-0610
Practice Address - Street 1:633 E RAY RD STE 133
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-4206
Practice Address - Country:US
Practice Address - Phone:480-782-0609
Practice Address - Fax:480-782-0610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-20
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ3872207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ879174Medicaid
AZ977358Medicaid
AZP33277Medicare UPIN
AZI19062Medicare UPIN
AZI45572Medicare UPIN
AZ977358Medicaid