Healthcare Provider Details

I. General information

NPI: 1669647996
Provider Name (Legal Business Name): MNM DENTAL STUDIO PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2008
Last Update Date: 04/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13933 W GRAND AVE SUITE #302
SURPRISE AZ
85374-2435
US

IV. Provider business mailing address

13933 W GRAND AVE SUITE #302
SURPRISE AZ
85374-2435
US

V. Phone/Fax

Practice location:
  • Phone: 623-209-0012
  • Fax: 623-537-9184
Mailing address:
  • Phone: 623-209-0012
  • Fax: 623-537-9184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD6611
License Number StateAZ

VIII. Authorized Official

Name: NICOLE BOLIO
Title or Position: INSURANCE COORDINATOR/RECEPTIONIST
Credential:
Phone: 623-209-0012