1699928523 NPI number — MOSAIC DENTISTRY PC

Table of content: (NPI 1699928523)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699928523 NPI number — MOSAIC DENTISTRY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOSAIC DENTISTRY PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699928523
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2933 S HOLGUIN WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHANDLER
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85286-3906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-821-8284
Provider Business Mailing Address Fax Number:
480-821-8284

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
290 W CHANDLER HEIGHTS RD
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
CHANDLER
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85248-5055
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-883-0222
Provider Business Practice Location Address Fax Number:
480-883-0332
Provider Enumeration Date:
10/23/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DOMINICK
Authorized Official First Name:
SAMUEL
Authorized Official Middle Name:
PETER
Authorized Official Title or Position:
PRESIDENT/MANAGER
Authorized Official Telephone Number:
480-821-8284

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  5248 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)