Provider Demographics
NPI:1023015914
Name:VALLECILLO & MENNA DENTISTRY, P.C.
Entity Type:Organization
Organization Name:VALLECILLO & MENNA DENTISTRY, P.C.
Other - Org Name:MONA LISA DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:ALBERTO
Authorized Official - Last Name:VALLECILLO
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-722-7600
Mailing Address - Street 1:936 E WILLIAMS FIELD RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-4881
Mailing Address - Country:US
Mailing Address - Phone:480-722-7600
Mailing Address - Fax:480-722-0111
Practice Address - Street 1:936 E WILLIAMS FIELD RD
Practice Address - Street 2:SUITE 101
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-4881
Practice Address - Country:US
Practice Address - Phone:480-722-7600
Practice Address - Fax:480-722-0111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ57781223G0001X
AZ58761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty