1386939148 NPI number — MICHAEL D ELLIOTT DMD PC

Table of content: (NPI 1386939148)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386939148 NPI number — MICHAEL D ELLIOTT DMD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHAEL D ELLIOTT DMD 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:
1386939148
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
564 W 9TH PL
Provider Second Line Business Mailing Address:
SUITE ONE
Provider Business Mailing Address City Name:
MESA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85201-4069
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-833-8064
Provider Business Mailing Address Fax Number:
480-962-8263

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
564 W 9TH PL
Provider Second Line Business Practice Location Address:
SUITE ONE
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85201-4069
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-833-8064
Provider Business Practice Location Address Fax Number:
480-962-8263
Provider Enumeration Date:
06/09/2011

Additional Information

Authorized Official

Authorized Official Last Name:
WINKELMAN
Authorized Official First Name:
KRYSTLE
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
480-833-8064

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  2410 , 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)

  • Identifier: 083353 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2410 . This is a "DENTAL LICENSE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com