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General NPI Number Information
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NPI Number | 1982134672
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Entity Type | Organization
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Legal Business Name | MESA DENTAL ARIZONA LLC
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Dates
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Enumeration Date | 06/14/2017
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Last Update Date | 06/14/2017
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Provider Practice Location Address
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Address Line | 1545 S POWER RD STE 112
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City | MESA
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State | AZ
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Zip | 85206
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Country | US
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Telephone | 480-924-6024
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Fax |
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Provider Business Mailing Address
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Address Line | 1 E WASHINGTON ST SUITE 500
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City | PHOENIX
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State | AZ
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Zip | 85004
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Country | US
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Telephone | 480-696-1095
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Fax |
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Authorized Official
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Title or Position | SOLE OWNER/ GENERAL DENTIST
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Name | MR. MARK WILKES MORRI
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Credential | DMD
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Telephone | 312-339-0588
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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 | 9690
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License Number State | AZ
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