Provider Demographics
NPI:1548516743
Name:MIRAGE DENTAL ASSOCIATES
Entity type:Organization
Organization Name:MIRAGE DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:MORONI
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:720-733-3440
Mailing Address - Street 1:85 RIO GRANDE DR.
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80104
Mailing Address - Country:US
Mailing Address - Phone:720-733-3440
Mailing Address - Fax:720-409-4155
Practice Address - Street 1:755 S PERRY ST STE 200
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80104-1923
Practice Address - Country:US
Practice Address - Phone:720-733-3440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-25
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO79421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty