Basic Information
Provider Information | |||||||||
NPI: | 1619148723 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTH MESA DENTAL, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | JUBILEE DENTAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1090 NORTHCHASE PKWY SE | ||||||||
Address2: | SUITE 150 | ||||||||
City: | MARIETTA | ||||||||
State: | GA | ||||||||
PostalCode: | 300676405 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7709165028 | ||||||||
FaxNumber: | 6782477858 | ||||||||
Practice Location | |||||||||
Address1: | 3711 GREGORY ST | ||||||||
Address2: |   | ||||||||
City: | WICHITA FALLS | ||||||||
State: | TX | ||||||||
PostalCode: | 763081614 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8009209947 | ||||||||
FaxNumber: | 6789045666 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/17/2008 | ||||||||
LastUpdateDate: | 06/17/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MAYFIELD | ||||||||
AuthorizedOfficialFirstName: | DALE | ||||||||
AuthorizedOfficialMiddleName: | G | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7709165036 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DMD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223E0200X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Endodontics | 1223P0221X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry | 1223S0112X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 1223G0001X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.