Provider Demographics
NPI:1992197016
Name:MAHALO DENTAL GROUP LLC
Entity Type:Organization
Organization Name:MAHALO DENTAL GROUP LLC
Other - Org Name:EL MIRAGE DENTAL EXCELLENCE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NYDEGGER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:623-882-1400
Mailing Address - Street 1:10111 N EL MIRAGE RD
Mailing Address - Street 2:SUITE #4
Mailing Address - City:EL MIRAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:85335-3605
Mailing Address - Country:US
Mailing Address - Phone:623-882-1540
Mailing Address - Fax:623-882-1300
Practice Address - Street 1:10111 N EL MIRAGE RD
Practice Address - Street 2:SUITE #4
Practice Address - City:EL MIRAGE
Practice Address - State:AZ
Practice Address - Zip Code:85335-3605
Practice Address - Country:US
Practice Address - Phone:623-882-1540
Practice Address - Fax:623-882-1300
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EL MIRAGE DENTAL EXCELLENCE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-02-26
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD5540122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ6196645Medicaid