Provider Demographics
NPI:1831301266
Name:DESERT LAKE FAMILY DENTISTRY INC
Entity Type:Organization
Organization Name:DESERT LAKE FAMILY DENTISTRY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ADEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAYEGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:6233-885-8888
Mailing Address - Street 1:10750 W MCDOWELL RD
Mailing Address - Street 2:#B200
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-5960
Mailing Address - Country:US
Mailing Address - Phone:623-388-5888
Mailing Address - Fax:623-388-5904
Practice Address - Street 1:10750 W MCDOWELL RD
Practice Address - Street 2:#B200
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-5960
Practice Address - Country:US
Practice Address - Phone:623-388-5888
Practice Address - Fax:623-388-5904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4772122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty