Healthcare Provider Details

I. General information

NPI: 1306338066
Provider Name (Legal Business Name): BULLEN ORTHODONTICS INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2018
Last Update Date: 05/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1143 RIATA VALLEY RD
KINGMAN AZ
86409
US

IV. Provider business mailing address

1143 RIATA VALLEY RD
KINGMAN AZ
86409
US

V. Phone/Fax

Practice location:
  • Phone: 928-757-8700
  • Fax: 928-757-0399
Mailing address:
  • Phone: 928-757-8700
  • Fax: 928-757-0399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD3927
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD3927
License Number StateAZ

VIII. Authorized Official

Name: DR. RYAN N. BULLEN
Title or Position: ORTHODONTIST
Credential:
Phone: 801-787-6883