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General NPI Number Information
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NPI Number | 1699792788
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Entity Type | Organization
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Legal Business Name | LAKE HAVASU CITY VALLEY DENTAL ASSOCIATES PC
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Dates
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Enumeration Date | 07/16/2006
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 1939 MCCULLOCH BLVD N STE 2
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-5652
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Country | US
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Telephone | 928-855-5041
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Fax | 928-855-2757
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Provider Business Mailing Address
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Address Line | 1939 MCCULLOCH BLVD #2
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403
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Country | US
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Telephone | 928-855-5041
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Fax | 928-855-2757
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Authorized Official
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Title or Position | ADMINISTRATIVE DIRECTOR
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Name | MRS. BETTY ANN HORN
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Credential |
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Telephone | 928-855-5041
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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 | AZ
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