Healthcare Provider Details

I. General information

NPI: 1851554240
Provider Name (Legal Business Name): JUST FOR KIDS DENTISTRY KINGMAN PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2008
Last Update Date: 07/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

2401 STOCKTON HILL RD STE 1
KINGMAN AZ
86401
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License NumberD6061
License Number StateAZ

VIII. Authorized Official

Name: MR. RONALD ANTHONY DICARLO II
Title or Position: PRESIDENT OWNER
Credential: DMD
Phone: 928-718-7188