MEDICARE: KKTZ DENTAL PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1912643578
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KKTZ DENTAL PLLC

Provider Business Mailing Address
First Line	:	2277 SWANSON AVE STE E
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-5991
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2277 SWANSON AVE STE E
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-5991
Country	:	US
Telephone Number	:	928-680-6222
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	GAYLE JENNINGS
Credential	:
Telephone Number	:	928-577-2533

Provider Enumeration Date	:	05/06/2022
Last Update Date	:	05/06/2022

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