Healthcare Provider Details

I. General information

NPI: 1093775488
Provider Name (Legal Business Name): RICHARD C. JIRSA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 02/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1229 WILLOW CREEK RD
PRESCOTT AZ
86301-1427
US

IV. Provider business mailing address

1229 WILLOW CREEK RD
PRESCOTT AZ
86301-1427
US

V. Phone/Fax

Practice location:
  • Phone: 928-778-2340
  • Fax: 928-778-3646
Mailing address:
  • Phone: 928-778-2340
  • Fax: 928-778-3646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number3843
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: