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General NPI Number Information
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NPI Number | 1063983245
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Entity Type | Organization
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Legal Business Name | RUSTIC MOUNTAIN DENTISTRY
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Dates
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Enumeration Date | 12/16/2018
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Last Update Date | 12/16/2018
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Provider Practice Location Address
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Address Line | 606 N MAIN STREET
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City | TAYLOR
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State | AZ
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Zip | 85939-8593
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Country | US
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Telephone | 928-457-0758
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Fax | 928-457-0821
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Provider Business Mailing Address
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Address Line | PO BOX 1550
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City | TAYLOR
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State | AZ
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Zip | 85939-1550
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Country | US
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Telephone | 928-457-0758
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Fax | 928-457-0821
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Authorized Official
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Title or Position | DOCTOR/OWNER
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Name | KENNETH HOUSTON DAVIS
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Credential | DMD
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Telephone | 928-457-0758
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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