Provider Demographics
NPI:1760611552
Name:EL MIRAGE DENTISTRY
Entity Type:Organization
Organization Name:EL MIRAGE DENTISTRY
Other - Org Name:CLASSICAL DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INS MGR
Authorized Official - Prefix:
Authorized Official - First Name:FAWNE
Authorized Official - Middle Name:E
Authorized Official - Last Name:PRYOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-582-3909
Mailing Address - Street 1:10111 N EL MIRAGE RD
Mailing Address - Street 2:
Mailing Address - City:EL MIRAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:85335-3605
Mailing Address - Country:US
Mailing Address - Phone:623-582-3909
Mailing Address - Fax:623-582-3902
Practice Address - Street 1:10111 N EL MIRAGE RD
Practice Address - Street 2:
Practice Address - City:EL MIRAGE
Practice Address - State:AZ
Practice Address - Zip Code:85335-3605
Practice Address - Country:US
Practice Address - Phone:623-582-3909
Practice Address - Fax:623-582-3902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-14
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD7345122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty