Provider Demographics
NPI:1255564506
Name:AN ELEGANT SMILE P.C.
Entity type:Organization
Organization Name:AN ELEGANT SMILE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:VITELA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-482-7000
Mailing Address - Street 1:980 WILLOW CREEK RD STE 103
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1619
Mailing Address - Country:US
Mailing Address - Phone:928-445-1682
Mailing Address - Fax:928-445-2963
Practice Address - Street 1:980 WILLOW CREEK RD STE 103
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1619
Practice Address - Country:US
Practice Address - Phone:928-445-1682
Practice Address - Fax:928-445-2963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-02
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ59791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty