Organization · NPI-2

1801 Southern Vista Dental Care

Dentist · Mesa, AZ

NPI number1023102183
StatusActive
Last updated in NPPESAug 22, 2020

Details

NPI
1023102183
Entity type
Organization (NPI-2)
Legal business name
1801 Southern Vista Dental Care
Organization subpart
No
Enumeration date
Oct 3, 2006
Last updated
Aug 22, 2020

Taxonomy and licenses

Taxonomy codeDescriptionLicenseStatePrimary
122300000X Dentist6591AZYes
122300000X Dentist6283AZ
122300000X Dentist2561AZ

Other names

  • Southern Vista Dental Care (Doing Business As)

Practice location

1801 E Southern Ave
Suite 103
Mesa, AZ 85204-5258

Phone 480-892-9000 · Fax 480-926-0545

Mailing address

1801 E Southern Ave
Suite 103
Mesa, AZ 85204-5258

Phone 480-892-9000 · Fax 480-926-0545

Authorized official

Elwynn Chad Caffall
Direct Owner
4808929000

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