# CHILDREN'S MEDICAID DENTAL CLINIC, PC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Children's Dental Clinic of W. Thomas Rd.
- **Organization subpart:** No

## Provider details

- **NPI number:** 1326025974
- **Authorized official:** MS. TRUDY WILLIAMS (DIRECTOR, LICENSING & CREDENTIALING)
- **Authorized official phone:** (615) 750-0342

## Contact information

- **Practice address:** 5115 W THOMAS RD, PHOENIX, AZ 85031-3944
- **Practice address phone:** (602) 233-3133
- **Practice address fax:** (602) 278-3139
- **Mailing address:** 201 W 8TH ST, SUITE 810, PUEBLO, CO 81003-3038
- **Mailing address phone:** (719) 562-4447

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | — | NULL | Yes |
| 1223G0001X | General Practice Dentistry | — | — | Yes |

## Other

- **Enumeration date:** 12/26/2005
- **Last updated:** 05/17/2010

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 619661 | — | AZ |