Provider Demographics
NPI:1356455422
Name:MECHAEL PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:MECHAEL PROFESSIONAL DENTAL CORPORATION
Other - Org Name:EL CAJON FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHATHA
Authorized Official - Middle Name:FARAJ
Authorized Official - Last Name:MECHAEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-466-1292
Mailing Address - Street 1:2720 FLETCHER PARKWAY
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020
Mailing Address - Country:US
Mailing Address - Phone:619-466-1292
Mailing Address - Fax:619-466-1561
Practice Address - Street 1:2720 FLETCHER PARKWAY
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020
Practice Address - Country:US
Practice Address - Phone:619-466-1292
Practice Address - Fax:619-466-1561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA310401223G0001X
CA479501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty