Organization
SHINE AZ LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JONATHAN BOLESTA DMD (OWNER)
(503) 877-8194
Entity
Organization
Contact information
Practice address
5940 W UNION HILLS DR, B 190, GLENDALE, AZ 85308-1308
(602) 314-4600
(602) 314-5506
Mailing address
5940 W UNION HILLS DR, B 190, GLENDALE, AZ 85308-1308
(602) 314-4600
(602) 314-5506
Taxonomy
Speciality
Code
Description
License number
State
261QD0000X
Dental Clinic/Center
Primary
7387
AZ
Other
Enumeration date
03/16/2011
Last updated
03/16/2011
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