Provider Demographics
NPI:1821494394
Name:MOUNTAINSIDE DENTAL CARE
Entity Type:Organization
Organization Name:MOUNTAINSIDE DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:H
Authorized Official - Last Name:HAYMORE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:520-297-5422
Mailing Address - Street 1:9000 N ORACLE RD
Mailing Address - Street 2:
Mailing Address - City:ORO VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-7400
Mailing Address - Country:US
Mailing Address - Phone:520-297-5422
Mailing Address - Fax:
Practice Address - Street 1:9000 N ORACLE RD
Practice Address - Street 2:
Practice Address - City:ORO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85704-7400
Practice Address - Country:US
Practice Address - Phone:520-297-5422
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-11
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ35781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1700218419OtherNPPES
AZ1093769671OtherNPPES
AZ1922034347OtherNPPES