1629570023 NPI number — DESERT ELITE FAMILY DENTAL PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629570023 NPI number — DESERT ELITE FAMILY DENTAL PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DESERT ELITE FAMILY DENTAL PLLC
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:
ELITE DENTAL, LLC
Provider Other Organization Name Type Code:
3
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:
1629570023
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1531 GEORGE DIETER DR APT 1004
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL PASO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79936-7673
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1300 EL PASEO RD STE N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS CRUCES
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88001-6039
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-205-6294
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/02/2018

Additional Information

Authorized Official

Authorized Official Last Name:
MINOOFAR
Authorized Official First Name:
MAZIAR
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/DMD
Authorized Official Telephone Number:
323-205-6294

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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