Healthcare Provider Details

I. General information

NPI: 1205667870
Provider Name (Legal Business Name): MESA IMPLANTS & PERIODONTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2024
Last Update Date: 08/13/2024
Certification Date: 08/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2812 N NORWALK BLDG 13 SUITE 126
MESA AZ
85215-1148
US

IV. Provider business mailing address

2812 N NORWALK BLDG 13126
MESA AZ
85215-1148
US

V. Phone/Fax

Practice location:
  • Phone: 480-203-2666
  • Fax: 480-939-2980
Mailing address:
  • Phone: 480-203-2666
  • Fax: 480-939-2980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: ELODIA MARIA GARCIA
Title or Position: OFFICE MANAGER
Credential:
Phone: 480-203-2666