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General NPI Number Information
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NPI Number | 1366914012
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Entity Type | Organization
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Legal Business Name | BLUE RIDGE FAMILY DENTISTRY, PC
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Dates
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Enumeration Date | 12/19/2018
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Last Update Date | 12/19/2018
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Provider Practice Location Address
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Address Line | 1450 E WHITE MOUNTAIN BLVD STE A
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City | PINETOP
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State | AZ
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Zip | 85935-7091
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Country | US
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Telephone | 928-367-4466
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 3768
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City | PINETOP
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State | AZ
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Zip | 85935-3768
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Country | US
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Telephone | 928-367-4466
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Fax |
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Authorized Official
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Title or Position | PRESIDENT, BRFD, PC
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Name | DR. JONATHAN HANRIDGE
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Credential | DDS
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Telephone | 928-367-4466
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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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