Healthcare Provider Details

I. General information

NPI: 1063602605
Provider Name (Legal Business Name): JUST FOR KIDS GENERAL DENTISTRY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2007
Last Update Date: 04/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 RIATA VALLEY RD STE 300
KINGMAN AZ
86409-3678
US

IV. Provider business mailing address

2401 STOCKTON HILL RD SUITE 1
KINGMAN AZ
86401-4189
US

V. Phone/Fax

Practice location:
  • Phone: 928-692-9315
  • Fax: 928-692-9408
Mailing address:
  • Phone: 928-718-7188
  • Fax: 928-718-7189

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: DR. RONALD ANTHONY DICARLO II
Title or Position: PRESIDENT/OWNER
Credential: D,M,D
Phone: 928-718-7188