1023015914 NPI number — VALLECILLO & MENNA DENTISTRY, P.C.

Table of content: (NPI 1023015914)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023015914 NPI number — VALLECILLO & MENNA DENTISTRY, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VALLECILLO & MENNA DENTISTRY, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MONA LISA DENTAL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023015914
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
936 E WILLIAMS FIELD RD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
GILBERT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85296-4881
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-722-7600
Provider Business Mailing Address Fax Number:
480-722-0111

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
936 E WILLIAMS FIELD RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
GILBERT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85296-4881
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-722-7600
Provider Business Practice Location Address Fax Number:
480-722-0111
Provider Enumeration Date:
07/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
VALLECILLO
Authorized Official First Name:
CARLOS
Authorized Official Middle Name:
ALBERTO
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
480-722-7600

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  5778 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223G0001X , with the licence number: 5876 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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