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General NPI Number Information
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NPI Number | 1588316806
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Entity Type | Organization
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Legal Business Name | CL VALLEY DENTAL
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Dates
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Enumeration Date | 01/19/2022
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Last Update Date | 01/20/2022
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Provider Practice Location Address
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Address Line | 5677 S HIGHWAY 95
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City | FORT MOHAVE
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State | AZ
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Zip | 86426-6049
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Country | US
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Telephone | 928-788-3359
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Fax | 928-768-6412
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Provider Business Mailing Address
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Address Line | 5677 S HIGHWAY 95
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City | FORT MOHAVE
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State | AZ
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Zip | 86426-6049
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Country | US
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Telephone | 928-788-3359
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Fax | 928-768-6412
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Authorized Official
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Title or Position | RDH
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Name | ELIZABETH AVERLAR
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Credential |
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Telephone | 928-788-3359
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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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