Basic Information
| Provider Information | |||||||||
| NPI: | 1003142597 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTH MESA DENTAL, PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | KOOL SMILES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 400 GALLERIA PKWY SE STE 800 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303396413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009209947 | ||||||||
| FaxNumber: | 6782477858 | ||||||||
| Practice Location | |||||||||
| Address1: | 6910 N MESA ST STE C | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799124446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009209947 | ||||||||
| FaxNumber: | 6782477858 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2009 | ||||||||
| LastUpdateDate: | 06/17/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MAYFIELD | ||||||||
| AuthorizedOfficialFirstName: | DALE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7709165036 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DMD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.