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General NPI Number Information
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NPI Number | 1457948622
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Entity Type | Organization
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Legal Business Name | MANN FORTUNA DENTAL, LLC
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Dates
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Enumeration Date | 12/22/2020
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Last Update Date | 12/22/2020
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Provider Practice Location Address
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Address Line | 11231 COMMERCIAL CENTER LOOP STE 105
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City | YUMA
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State | AZ
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Zip | 85367-7474
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Country | US
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Telephone | 928-783-8300
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Fax |
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Provider Business Mailing Address
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Address Line | 11231 COMMERCIAL CENTER LOOP STE 105
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City | YUMA
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State | AZ
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Zip | 85367-7474
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Country | US
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Telephone | 928-783-8300
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | ASHAM DEEP KAUR
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Credential |
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Telephone | 510-378-9802
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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 |
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License Number State |
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