Provider Demographics
NPI:1932518594
Name:AN ELEGANT SMILE DENTISTRY
Entity Type:Organization
Organization Name:AN ELEGANT SMILE DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:FOREMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-323-8537
Mailing Address - Street 1:14155 N 83RD AVE STE 113
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-5655
Mailing Address - Country:US
Mailing Address - Phone:623-486-5222
Mailing Address - Fax:
Practice Address - Street 1:14155 N 83RD AVE STE 113
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-5655
Practice Address - Country:US
Practice Address - Phone:623-486-5222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-07
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD009056122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty