Provider Demographics
NPI:1548307424
Name:DESERT VISTA DENTAL WEST PLLC
Entity type:Organization
Organization Name:DESERT VISTA DENTAL WEST PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:STACY
Authorized Official - Middle Name:K
Authorized Official - Last Name:CORDOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-935-2755
Mailing Address - Street 1:1646 N LITCHFIELD RD
Mailing Address - Street 2:SUITE 125
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-1203
Mailing Address - Country:US
Mailing Address - Phone:623-935-2755
Mailing Address - Fax:623-935-0265
Practice Address - Street 1:1646 N LITCHFIELD RD
Practice Address - Street 2:SUITE 125
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-1203
Practice Address - Country:US
Practice Address - Phone:623-935-2755
Practice Address - Fax:623-935-0265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty