Provider Demographics
NPI:1285955088
Name:AN ELEGANT SMILE P.C.
Entity type:Organization
Organization Name:AN ELEGANT SMILE P.C.
Other - Org Name:<UNAVAIL>
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 1:1360 W IRVINGTON RD STE 180
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85746-4110
Mailing Address - Country:US
Mailing Address - Phone:520-206-0030
Mailing Address - Fax:520-889-0750
Practice Address - Street 1:1360 W IRVINGTON RD STE 180
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85746-4110
Practice Address - Country:US
Practice Address - Phone:520-206-0030
Practice Address - Fax:520-889-0750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-15
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ76991223G0001X
AZ33171223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty