Provider Demographics
NPI:1629138367
Name:SUPERSTITION MOUNTAIN DENTAL, INC.
Entity Type:Organization
Organization Name:SUPERSTITION MOUNTAIN DENTAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:LOVELL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:480-671-7777
Mailing Address - Street 1:5331 S. SUPERSTITION SPRINGS DR.
Mailing Address - Street 2:STE. 108
Mailing Address - City:GOLD CANYON
Mailing Address - State:AZ
Mailing Address - Zip Code:85218
Mailing Address - Country:US
Mailing Address - Phone:480-671-7777
Mailing Address - Fax:481-671-7785
Practice Address - Street 1:5331 S. SUPERSTITION SPRINGS DR.
Practice Address - Street 2:STE. 108
Practice Address - City:GOLD CANYON
Practice Address - State:AZ
Practice Address - Zip Code:85218
Practice Address - Country:US
Practice Address - Phone:480-671-7777
Practice Address - Fax:481-671-7785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty