Provider Demographics
NPI:1003142597
Name:NORTH MESA DENTAL, PC
Entity Type:Organization
Organization Name:NORTH MESA DENTAL, PC
Other - Org Name:KOOL SMILES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-916-5036
Mailing Address - Street 1:400 GALLERIA PKWY SE STE 800
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-6413
Mailing Address - Country:US
Mailing Address - Phone:800-920-9947
Mailing Address - Fax:678-247-7858
Practice Address - Street 1:6910 N MESA ST STE C
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-4446
Practice Address - Country:US
Practice Address - Phone:800-920-9947
Practice Address - Fax:678-247-7858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-19
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty