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General NPI Number Information
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NPI Number | 1720827652
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Entity Type | Organization
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Legal Business Name | PRESCOTT VALLEY PDC PLLC
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Dates
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Enumeration Date | 05/21/2024
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Last Update Date | 05/21/2024
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Provider Practice Location Address
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Address Line | 7890 E FLORENTINE RD
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City | PRESCOTT VALLEY
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State | AZ
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Zip | 86314-1204
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Country | US
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Telephone | 928-772-9860
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Fax |
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Provider Business Mailing Address
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Address Line | 355 S 520 W STE 250
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City | LINDON
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State | UT
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Zip | 84042-1976
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING SPECIALIST
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Name | MARK CHRISTENSEN
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Credential |
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Telephone | 801-305-3460
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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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