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General NPI Number Information
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NPI Number | 1639783749
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Entity Type | Organization
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Legal Business Name | PRESCOTT VALLEY ENDODONTIC ASSOCIATES, PLLC
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Dates
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Enumeration Date | 09/04/2020
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Last Update Date | 09/04/2020
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Provider Practice Location Address
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Address Line | 8053 E FLORENTINE RD
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City | PRESCOTT VALLEY
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State | AZ
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Zip | 86314-9423
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Country | US
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Telephone | 928-771-1640
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Fax | 928-771-1640
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Provider Business Mailing Address
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Address Line | 1658 OAKLAWN DR
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City | PRESCOTT
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State | AZ
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Zip | 86305-1110
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Country | US
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Telephone | 928-771-1640
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Fax | 928-771-1640
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Authorized Official
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Title or Position | MANAGER
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Name | JORDAN OHLSON
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Credential |
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Telephone | 928-771-1640
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number |
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License Number State |
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