=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588322598
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PINEVIEW PRESCOTT DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/07/2021
-----------------------------------------------------
Last Update Date | 12/07/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 680 GAIL GARDNER WAY
-----------------------------------------------------
City | PRESCOTT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86305-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-445-9233
-----------------------------------------------------
Fax | 928-445-1758
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 680 GAIL GARDNER WAY
-----------------------------------------------------
City | PRESCOTT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86305-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-445-9233
-----------------------------------------------------
Fax | 928-445-1758
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DOCTOR
-----------------------------------------------------
Name | DR. KENNETH GLASS
-----------------------------------------------------
Credential | DDS.
-----------------------------------------------------
Telephone | 928-445-9233
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------