Healthcare Provider Details

I. General information

NPI: 1386939148
Provider Name (Legal Business Name): MICHAEL D ELLIOTT DMD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2011
Last Update Date: 06/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

564 W 9TH PL SUITE ONE
MESA AZ
85201-4069
US

IV. Provider business mailing address

564 W 9TH PL SUITE ONE
MESA AZ
85201-4069
US

V. Phone/Fax

Practice location:
  • Phone: 480-833-8064
  • Fax: 480-962-8263
Mailing address:
  • Phone: 480-833-8064
  • Fax: 480-962-8263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2410
License Number StateAZ

VIII. Authorized Official

Name: KRYSTLE WINKELMAN
Title or Position: MANAGER
Credential:
Phone: 480-833-8064