Provider Demographics
NPI:1245089952
Name:MARYVALE CHILDREN'S DENTISTRY AND ORTHODONTICS PLLC
Entity type:Organization
Organization Name:MARYVALE CHILDREN'S DENTISTRY AND ORTHODONTICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGUIRE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-432-3363
Mailing Address - Street 1:12945 S 176TH LN
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-5786
Mailing Address - Country:US
Mailing Address - Phone:480-432-3363
Mailing Address - Fax:
Practice Address - Street 1:4700 N 51ST AVE STE 3
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85031-1237
Practice Address - Country:US
Practice Address - Phone:480-432-3363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental