Provider Demographics
NPI:1053631309
Name:AN ELEGANT SMILE P.C.
Entity type:Organization
Organization Name:AN ELEGANT SMILE P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:VITELA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-482-7000
Mailing Address - Street 1:1425 S GREENFIELD RD
Mailing Address - Street 2:BLDG 2 STE 110
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-5529
Mailing Address - Country:US
Mailing Address - Phone:480-854-3434
Mailing Address - Fax:480-854-2640
Practice Address - Street 1:1425 S GREENFIELD RD
Practice Address - Street 2:BLDG 2 STE 110
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-5529
Practice Address - Country:US
Practice Address - Phone:480-854-3434
Practice Address - Fax:480-854-2640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-09
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty