1831675263 NPI number — MY DENTAL L.L.C.

Table of content: (NPI 1831675263)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831675263 NPI number — MY DENTAL L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MY DENTAL L.L.C.
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:
MY DENTAL L.L.C.
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:
1831675263
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/18/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2001 W BETHANY HOME RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85015-2471
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-249-9621
Provider Business Mailing Address Fax Number:
602-841-1916

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
725 N CENTRAL AVE STE 109
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AVONDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85323-1659
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-322-4575
Provider Business Practice Location Address Fax Number:
623-322-4312
Provider Enumeration Date:
07/18/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MAMOOK
Authorized Official First Name:
YOUIL
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
DR./OWNER
Authorized Official Telephone Number:
480-388-7049

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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