Healthcare Provider Details

I. General information

NPI: 1760469787
Provider Name (Legal Business Name): MICHAEL DOTSON ELLIOTT D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2005
Last Update Date: 01/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

564 W 9TH PL SUITE 1
MESA AZ
85201-4069
US

IV. Provider business mailing address

564 W 9TH PL SUITE 1
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:
Title or Position:
Credential:
Phone: