Provider Demographics
NPI:1033467113
Name:MAMOLA, ELAINE CARMELLA (RDH)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:CARMELLA
Last Name:MAMOLA
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15508 W BELL RD
Mailing Address - Street 2:101-525
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-2432
Mailing Address - Country:US
Mailing Address - Phone:623-584-4746
Mailing Address - Fax:623-584-4750
Practice Address - Street 1:15508 W BELL RD
Practice Address - Street 2:101-525
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-2432
Practice Address - Country:US
Practice Address - Phone:623-584-4746
Practice Address - Fax:623-584-4750
Is Sole Proprietor?:No
Enumeration Date:2012-08-21
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZH04804124Q00000X
AZH05302124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist