Basic Information
| Provider Information | |||||||||
| NPI: | 1114565744 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WEST VALLEY BRACES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14100 N 83RD AVE STE 280 | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853815660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6239359873 | ||||||||
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| Practice Location | |||||||||
| Address1: | 14100 N 83RD AVE STE 280 | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853815660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6239359873 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2019 | ||||||||
| LastUpdateDate: | 12/13/2019 | ||||||||
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| AuthorizedOfficialLastName: | BARNES | ||||||||
| AuthorizedOfficialFirstName: | TERRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERSATIONS | ||||||||
| AuthorizedOfficialTelephone: | 6239359873 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/13/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223X0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics |
No ID Information.