Organization
FIESTA KIDTASTIC, LLC
Active
Other names
Fiesta Kidtastics
Organization subpart
No
Provider details
NPI number
Authorized official
MS. JAIME JOHNSON (CONTROLLER)
(480) 648-4037
Entity
Organization
Contact information
Practice address
1303 S LONGMORE STE 1, MESA, AZ 85202-9607
(480) 648-4037
(480) 696-5505
Mailing address
4704 E SOUTHERN AVE, MESA, AZ 85206-2737
(480) 648-4037
(480) 696-5505
Taxonomy
Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
Primary
—
—
Other
Enumeration date
11/06/2012
Last updated
12/06/2013
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