Provider Demographics
NPI:1447780135
Name:MESA DENTAL ARIZONA LLC
Entity Type:Organization
Organization Name:MESA DENTAL ARIZONA LLC
Other - Org Name:SOUTHERN DENTAL
Other - Org Type:Other Name
Authorized Official - Title/Position:SOLE OWNER/GENERAL DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:WILKES
Authorized Official - Last Name:MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:312-339-0588
Mailing Address - Street 1:1 EAST WASHINGTON ST STE 500
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004
Mailing Address - Country:US
Mailing Address - Phone:480-696-1095
Mailing Address - Fax:
Practice Address - Street 1:3320 W SOUTHERN AVE #111
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041
Practice Address - Country:US
Practice Address - Phone:602-305-8800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MESA DENTAL ARIZONA LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-06-14
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9690122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty