Provider Demographics
NPI:1215283940
Name:MIDEX DENTAL, LLC
Entity type:Organization
Organization Name:MIDEX DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:VELASCO
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:602-206-6964
Mailing Address - Street 1:652 E WARNER RD
Mailing Address - Street 2:STE 101
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-3071
Mailing Address - Country:US
Mailing Address - Phone:480-545-8400
Mailing Address - Fax:
Practice Address - Street 1:6337 N 75TH ST
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85250-4623
Practice Address - Country:US
Practice Address - Phone:602-206-6964
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-31
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ3740122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty