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General NPI Number Information
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NPI Number | 1760611552
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Entity Type | Organization
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Legal Business Name | EL MIRAGE DENTISTRY
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Dates
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Enumeration Date | 07/14/2009
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Last Update Date | 07/14/2009
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Provider Practice Location Address
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Address Line | 10111 N EL MIRAGE RD
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City | EL MIRAGE
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State | AZ
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Zip | 85335-3605
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Country | US
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Telephone | 623-582-3909
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Fax | 623-582-3902
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Provider Business Mailing Address
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Address Line | 10111 N EL MIRAGE RD
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City | EL MIRAGE
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State | AZ
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Zip | 85335-3605
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Country | US
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Telephone | 623-582-3909
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Fax | 623-582-3902
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Authorized Official
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Title or Position | INS MGR
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Name | FAWNE E PRYOR
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Credential |
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Telephone | 623-582-3909
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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 | D7345
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License Number State | AZ
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