Healthcare Provider Details

I. General information

NPI: 1164591863
Provider Name (Legal Business Name): JENNIFER THOMAS MIRABELLI DMD, MSD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 N 44TH ST #101
PHOENIX AZ
85018-2782
US

IV. Provider business mailing address

4901 N 44TH ST #101
PHOENIX AZ
85018-2782
US

V. Phone/Fax

Practice location:
  • Phone: 602-595-3531
  • Fax: 602-595-3431
Mailing address:
  • Phone: 602-595-3531
  • Fax: 602-595-3431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number6007
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: