# KATSUR DENTAL OF ARIZONA, INC.

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Katsur Dental of Arizona
- **Organization subpart:** No

## Provider details

- **NPI number:** 1174771612
- **Authorized official:** TERRI GARDINER (CREDENTIALING COORDINATOR)
- **Authorized official phone:** (407) 772-5124

## Contact information

- **Practice address:** 105 N LITCHFIELD RD, GOODYEAR, AZ 85338-1617
- **Practice address phone:** (623) 932-3200
- **Practice address fax:** (623) 932-3222
- **Mailing address:** 926 GREAT POND DR, SUITE 5000, ALTAMONTE SPRINGS, FL 32714-7244
- **Mailing address phone:** (407) 772-5124
- **Mailing address fax:** (407) 788-3572

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | 5216 | AZ | Yes |
| 1223G0001X | General Practice Dentistry | 5795 | AZ | — |

## Other

- **Enumeration date:** 09/08/2008
- **Last updated:** 11/12/2010

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 197645 | ONET AHCCCS\# | AZ |
| 01 | — | 294311 | LOAN KIM DAO AHCCCS\# | AZ |
| 01 | — | 368780 | GROUP AHCCCS\# | AZ |
| 01 | — | 506058 | TURNER AHCCCS\# | AZ |
| 01 | — | 561921 | WHATCOTT AHCCCS\# | AZ |
| 01 | — | 565806 | SANTORO AHCCCS\# | AZ |
| 01 | — | 774457 | SKAALEN AHCCCS\# | AZ |