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General NPI Number Information
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NPI Number | 1043466782
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Entity Type | Organization
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Legal Business Name | 16TH STREET DENTAL CARE
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Dates
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Enumeration Date | 08/13/2008
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Last Update Date | 08/13/2008
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Provider Practice Location Address
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Address Line | 1325 W 16TH ST SUITE 4
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City | YUMA
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State | AZ
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Zip | 85364-4496
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Country | US
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Telephone | 928-782-3839
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Fax | 928-329-9029
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Provider Business Mailing Address
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Address Line | 1325 W 16TH ST SUITE 4
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City | YUMA
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State | AZ
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Zip | 85364-4496
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Country | US
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Telephone | 928-782-3839
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Fax | 928-329-9029
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | CARRIE FREEZE
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Credential |
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Telephone | 928-782-3839
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D7288
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License Number State | AZ
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