Healthcare Provider Details

I. General information

NPI: 1609475060
Provider Name (Legal Business Name): HAPPY MOLAR DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2020
Last Update Date: 12/10/2020
Certification Date: 12/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 N DOBSON RD STE A-104
MESA AZ
85201-6822
US

IV. Provider business mailing address

3695 E LONGHORN DR
GILBERT AZ
85297-7820
US

V. Phone/Fax

Practice location:
  • Phone: 480-900-7838
  • Fax: 480-999-3478
Mailing address:
  • Phone: 773-988-5889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHELLE LY
Title or Position: OWNER
Credential: DMD
Phone: 480-900-7838