Provider Demographics
NPI:1538488804
Name:AN ELEGANT SMILE P.C.
Entity Type:Organization
Organization Name:AN ELEGANT SMILE P.C.
Other - Org Name:AN ELEGANT SMILE DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:VITELA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-482-7000
Mailing Address - Street 1:5977 E GRANT RD
Mailing Address - Street 2:STE 115
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-2341
Mailing Address - Country:US
Mailing Address - Phone:520-733-0040
Mailing Address - Fax:520-546-0374
Practice Address - Street 1:5977 E GRANT RD
Practice Address - Street 2:STE 115
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2341
Practice Address - Country:US
Practice Address - Phone:520-733-0040
Practice Address - Fax:520-546-0374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-25
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ76221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty