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General NPI Number Information
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NPI Number | 1104955509
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Entity Type | Organization
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Legal Business Name | AMERICAN DENTAL CENTER INC
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Dates
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Enumeration Date | 03/04/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1050 E UNIVERSITY DR STE 11
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City | MESA
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State | AZ
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Zip | 85203-8046
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Country | US
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Telephone | 480-610-2401
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Fax |
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Provider Business Mailing Address
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Address Line | 1050 E UNIVERSITY DR STE 11
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City | MESA
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State | AZ
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Zip | 85203-8046
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Country | US
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Telephone | 480-610-2401
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | LORENA MOORHEAD
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Credential | D.D.S
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Telephone | 480-610-2401
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 4631
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License Number State | AZ
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