Provider Demographics
NPI:1588942494
Name:DESIRAE DENTAL SERVICES, PLLC
Entity type:Organization
Organization Name:DESIRAE DENTAL SERVICES, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STERLING
Authorized Official - Middle Name:
Authorized Official - Last Name:DECKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-814-6670
Mailing Address - Street 1:2872 JAMAICA BLVD S
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86406-7707
Mailing Address - Country:US
Mailing Address - Phone:928-680-7645
Mailing Address - Fax:928-680-9466
Practice Address - Street 1:2872 JAMAICA BLVD S
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86406-7707
Practice Address - Country:US
Practice Address - Phone:928-680-7645
Practice Address - Fax:928-680-9466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-26
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes126800000XDental ProvidersDental AssistantGroup - Single Specialty