Provider Demographics
NPI:1114406329
Name:DESERT STAR DENTAL, PLLC
Entity Type:Organization
Organization Name:DESERT STAR DENTAL, PLLC
Other - Org Name:MIRADOR DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:FATIMA
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:510-289-2261
Mailing Address - Street 1:216 W JASPER DR
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233-8333
Mailing Address - Country:US
Mailing Address - Phone:510-289-2261
Mailing Address - Fax:
Practice Address - Street 1:894 E WARNER RD # B105
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-2935
Practice Address - Country:US
Practice Address - Phone:480-471-8553
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental