Healthcare Provider Details

I. General information

NPI: 1932799053
Provider Name (Legal Business Name): WILD WEST KIDS DENTAL BULLHEAD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2021
Last Update Date: 01/22/2021
Certification Date: 01/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 MIRACLE MILE
BULLHEAD CITY AZ
86442-7311
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 928-704-5573
  • Fax:
Mailing address:
  • Phone: 928-718-7188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. RONALD A DICARLO II
Title or Position: OWNER
Credential: DMD
Phone: 928-718-7188