Provider Demographics
NPI:1891594016
Name:MIRROR IMAGE DENTAL LLC
Entity type:Organization
Organization Name:MIRROR IMAGE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO / OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:MAULE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:602-705-9168
Mailing Address - Street 1:1601 E POTTER DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85024-4334
Mailing Address - Country:US
Mailing Address - Phone:602-705-9168
Mailing Address - Fax:
Practice Address - Street 1:4710 E CACTUS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-7706
Practice Address - Country:US
Practice Address - Phone:480-442-0225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-11
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental