Healthcare Provider Details

I. General information

NPI: 1154827160
Provider Name (Legal Business Name): JUST FOR KIDS DENTAL GROUP BULLHEAD, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2018
Last Update Date: 03/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2580 HWAY 95 STE 101
BULLHEAD CITY AZ
86442-7324
US

IV. Provider business mailing address

2401 N STOCKTON HILL RD STE 1
KINGMAN AZ
86401-4189
US

V. Phone/Fax

Practice location:
  • Phone: 928-718-7188
  • Fax:
Mailing address:
  • Phone: 928-718-7188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DAVID STEFFEN
Title or Position: REGIONAL OFFICE MANGER
Credential:
Phone: 928-718-7188