MEDICARE: EMBRACEABLE AZ LLC

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	8340	AZ

General Provider Information

NPI Number	:	1851644504
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMBRACEABLE AZ LLC

Provider Business Mailing Address
First Line	:	1130 S COUNTRY CLUB DR
Second Line	:	SUITE 101
City	:	MESA
State	:	AZ
Zip	:	85210-4639
Country	:	US
Telephone Number	:	480-461-9866
Fax Number	:

Provider Business Practice Location Address
First Line	:	1130 S COUNTRY CLUB DR
Second Line	:	SUITE 101
City	:	MESA
State	:	AZ
Zip	:	85210-4639
Country	:	US
Telephone Number	:	480-461-9866
Fax Number	:

Authorized Official
Title or Position	:	PARTNER / OWNER
Name	:	DR. MARK STASI
Credential	:	D.D.S.
Telephone Number	:	303-549-1912

Provider Enumeration Date	:	10/18/2012
Last Update Date	:	10/18/2012

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