Provider Demographics
NPI:1518270248
Name:MOUNTAINSIDE DENTAL GROUP, LLC
Entity Type:Organization
Organization Name:MOUNTAINSIDE DENTAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DARON
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-981-0590
Mailing Address - Street 1:6549 E UNIVERSITY DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-7600
Mailing Address - Country:US
Mailing Address - Phone:480-981-0590
Mailing Address - Fax:
Practice Address - Street 1:6549 E UNIVERSITY DR
Practice Address - Street 2:SUITE B
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-7600
Practice Address - Country:US
Practice Address - Phone:480-981-0590
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-22
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZL160758801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty