=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760536957
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ARIZONA DENTAL PROFESSIONALS, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2007
-----------------------------------------------------
Last Update Date | 02/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3699 HIGHWAY 95 STE 950
-----------------------------------------------------
City | BULLHEAD CITY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86442-8215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-758-0008
-----------------------------------------------------
Fax | 928-758-0009
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3015 HIGHWAY 95 SUITE 112
-----------------------------------------------------
City | BULLHEAD CITY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86442-4334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-758-0008
-----------------------------------------------------
Fax | 928-758-0009
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING COORDINATOR
-----------------------------------------------------
Name | CEMYIRA MCDOUGAL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 217-764-8609
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------