Healthcare Provider Details

I. General information

NPI: 1285955088
Provider Name (Legal Business Name): AN ELEGANT SMILE P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2010
Last Update Date: 09/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1360 W IRVINGTON RD STE 180
TUCSON AZ
85746-4110
US

IV. Provider business mailing address

1360 W IRVINGTON RD STE 180
TUCSON AZ
85746-4110
US

V. Phone/Fax

Practice location:
  • Phone: 520-206-0030
  • Fax: 520-889-0750
Mailing address:
  • Phone: 520-206-0030
  • Fax: 520-889-0750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7699
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number3317
License Number StateAZ

VIII. Authorized Official

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