MEDICARE: AN ELEGANT SMILE P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	5979	AZ

General Provider Information

NPI Number	:	1255564506
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AN ELEGANT SMILE P.C.

Provider Business Mailing Address
First Line	:	980 WILLOW CREEK RD STE 103
Second Line	:
City	:	PRESCOTT
State	:	AZ
Zip	:	86301-1619
Country	:	US
Telephone Number	:	928-445-1682
Fax Number	:	928-445-2963

Provider Business Practice Location Address
First Line	:	980 WILLOW CREEK RD STE 103
Second Line	:
City	:	PRESCOTT
State	:	AZ
Zip	:	86301-1619
Country	:	US
Telephone Number	:	928-445-1682
Fax Number	:	928-445-2963

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	MONICA VITELA
Credential	:
Telephone Number	:	602-482-7000

Provider Enumeration Date	:	09/02/2009
Last Update Date	:	09/02/2009

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