Healthcare Provider Details

I. General information

NPI: 1740190917
Provider Name (Legal Business Name): WOW DENTAL AZ, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 FRONTAGE RD
BULLHEAD CITY AZ
86442-8154
US

IV. Provider business mailing address

PO BOX 70887
CLEVELAND OH
44190-0887
US

V. Phone/Fax

Practice location:
  • Phone: 928-704-0220
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MARIANNE TILTON
Title or Position: PROVIDER ENROLLMENT SUPERVISOR
Credential:
Phone: 315-454-6000