Healthcare Provider Details

I. General information

NPI: 1629570023
Provider Name (Legal Business Name): DESERT ELITE FAMILY DENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 EL PASEO RD STE N
LAS CRUCES NM
88001-6039
US

IV. Provider business mailing address

1531 GEORGE DIETER DR APT 1004
EL PASO TX
79936-7673
US

V. Phone/Fax

Practice location:
  • Phone: 323-205-6294
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. MAZIAR MINOOFAR
Title or Position: PRESIDENT/DMD
Credential: DMD
Phone: 323-205-6294