Healthcare Provider Details

I. General information

NPI: 1285873125
Provider Name (Legal Business Name): AN ELEGANT SMILE P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2009
Last Update Date: 02/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4550 E BELL RD STE 8-178
PHOENIX AZ
85032-9306
US

IV. Provider business mailing address

4550 E BELL RD STE 8-178
PHOENIX AZ
85032
US

V. Phone/Fax

Practice location:
  • Phone: 602-494-3000
  • Fax: 602-494-3005
Mailing address:
  • Phone: 602-494-3000
  • Fax: 602-494-3005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: MONICA VITELA
Title or Position: CREDENTIAL COORDINATOR
Credential:
Phone: 602-482-7000