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General NPI Number Information
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NPI Number | 1154742377
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Entity Type | Organization
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Legal Business Name | ORTHODONTICS OF YUMA, P.C,
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Dates
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Enumeration Date | 12/16/2013
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Last Update Date | 12/16/2013
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Provider Practice Location Address
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Address Line | 1030 W 24TH ST STE C-1
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City | YUMA
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State | AZ
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Zip | 85364-8319
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Country | US
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Telephone | 928-343-9559
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Fax |
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Provider Business Mailing Address
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Address Line | 4760 N BUTLER AVE STE B1
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City | FARMINGTON
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State | NM
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Zip | 87401-0816
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Country | US
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Telephone | 505-325-8858
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Fax | 505-325-2532
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Authorized Official
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Title or Position | OWNER
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Name | JOSEPH A. WILSON
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Credential | DMD
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Telephone | 505-325-8858
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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 | 8613
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 8613
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License Number State | AZ
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