Provider Demographics
NPI:1609284801
Name:DESERT MOUNTAIN ENDODONTICS
Entity Type:Organization
Organization Name:DESERT MOUNTAIN ENDODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:CASALE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:623-594-2888
Mailing Address - Street 1:20542 N LAKE PLEASANT RD
Mailing Address - Street 2:#113
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-9749
Mailing Address - Country:US
Mailing Address - Phone:623-594-2888
Mailing Address - Fax:623-328-9474
Practice Address - Street 1:20542 N LAKE PLEASANT RD
Practice Address - Street 2:#113
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-9749
Practice Address - Country:US
Practice Address - Phone:623-594-2888
Practice Address - Fax:623-328-9474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-31
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8110302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization