Provider Demographics
NPI:1659462372
Name:MESA DENTAL GROUP LLC
Entity Type:Organization
Organization Name:MESA DENTAL GROUP LLC
Other - Org Name:GILBERT ROAD DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BARTEL
Authorized Official - Middle Name:
Authorized Official - Last Name:VANOOSTENDORP
Authorized Official - Suffix:V
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-649-7200
Mailing Address - Street 1:2017 E ADOBE ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-6740
Mailing Address - Country:US
Mailing Address - Phone:480-649-7200
Mailing Address - Fax:480-649-7219
Practice Address - Street 1:2017 E ADOBE ST
Practice Address - Street 2:SUITE 6
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85213-6740
Practice Address - Country:US
Practice Address - Phone:480-649-7200
Practice Address - Fax:480-649-7219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD5677122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty