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General NPI Number Information
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NPI Number | 1760773907
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Entity Type | Organization
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Legal Business Name | ARIZONA DENTAL SLEEP THERAPY
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Dates
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Enumeration Date | 04/21/2011
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Last Update Date | 04/21/2011
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Provider Practice Location Address
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Address Line | 1845 MCCULLOCH BLVD N STE A1
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-5722
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Country | US
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Telephone | 928-855-7700
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Fax | 928-855-7703
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Provider Business Mailing Address
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Address Line | 1845 MCCULLOCH BLVD N STE A1
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-5722
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Country | US
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Telephone | 928-855-7700
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Fax | 928-855-7703
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Authorized Official
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Title or Position | DOCTOR
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Name | DR. RONNIE LYNN COOK
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Credential | D.D.S., M.S.D.
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Telephone | 928-855-7700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | AZ1687
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License Number State | AZ
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