Provider Demographics
NPI:1730574799
Name:ELITE DENTAL GROUP, LLC
Entity type:Organization
Organization Name:ELITE DENTAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:YOUIL
Authorized Official - Middle Name:G
Authorized Official - Last Name:MAMOOK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:602-249-9621
Mailing Address - Street 1:2001 W BETHANY HOME RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-2471
Mailing Address - Country:US
Mailing Address - Phone:602-249-9621
Mailing Address - Fax:602-841-1916
Practice Address - Street 1:2001 W BETHANY HOME RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-2471
Practice Address - Country:US
Practice Address - Phone:602-249-9621
Practice Address - Fax:602-841-1916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-06
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ06072122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty