Provider Demographics
NPI:1386939148
Name:MICHAEL D ELLIOTT DMD PC
Entity type:Organization
Organization Name:MICHAEL D ELLIOTT DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KRYSTLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WINKELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-833-8064
Mailing Address - Street 1:564 W 9TH PL
Mailing Address - Street 2:SUITE ONE
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-4069
Mailing Address - Country:US
Mailing Address - Phone:480-833-8064
Mailing Address - Fax:480-962-8263
Practice Address - Street 1:564 W 9TH PL
Practice Address - Street 2:SUITE ONE
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-4069
Practice Address - Country:US
Practice Address - Phone:480-833-8064
Practice Address - Fax:480-962-8263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-09
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ24101223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ083353Medicaid
AZ2410OtherDENTAL LICENSE
AZZ526684932Medicare PIN
AZ083353Medicaid