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General NPI Number Information
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NPI Number | 1497402465
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Entity Type | Organization
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Legal Business Name | SOUTH FRONTAGE ROAD DENTAL PLLC
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Dates
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Enumeration Date | 03/09/2022
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Last Update Date | 03/09/2022
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Provider Practice Location Address
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Address Line | 11259 S FRONTAGE RD STE 103
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City | YUMA
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State | AZ
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Zip | 85367-7883
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Country | US
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Telephone | 928-342-7351
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Fax |
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Provider Business Mailing Address
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Address Line | 11259 S FRONTAGE RD STE 103
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City | YUMA
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State | AZ
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Zip | 85367-7883
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Country | US
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Telephone | 928-342-7351
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING LEAD
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Name | VICENTA REYES
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Credential |
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Telephone | 972-869-3789
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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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