Healthcare Provider Details

I. General information

NPI: 1295163418
Provider Name (Legal Business Name): DESERT FAMILY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2013
Last Update Date: 10/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1911 W MAIN ST #6
MESA AZ
85201-6929
US

IV. Provider business mailing address

1911 W MAIN ST #6
MESA AZ
85201-6929
US

V. Phone/Fax

Practice location:
  • Phone: 480-838-4185
  • Fax: 480-838-8746
Mailing address:
  • Phone: 480-838-4185
  • Fax: 480-838-8746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number8303
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7570
License Number StateAZ

VIII. Authorized Official

Name: SCOTT RYAN LEE
Title or Position: OWNER
Credential: DDS
Phone: 480-838-4185