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General NPI Number Information
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NPI Number | 1891244281
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Entity Type | Organization
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Legal Business Name | PRESCOTT PERIODONTICS & IMPLANT DENTISTRY, PLLC
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Dates
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Enumeration Date | 09/26/2016
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Last Update Date | 09/26/2016
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Provider Practice Location Address
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Address Line | 1229 WILLOW CREEK RD
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City | PRESCOTT
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State | AZ
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Zip | 86301-1427
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Country | US
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Telephone | 928-778-2340
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Fax | 928-778-3646
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Provider Business Mailing Address
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Address Line | 1229 WILLOW CREEK RD
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City | PRESCOTT
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State | AZ
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Zip | 86301-1427
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Country | US
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Telephone | 928-778-2340
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Fax | 928-778-3646
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Authorized Official
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Title or Position | PERIODONTIST
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Name | DR. RICHARD CHARLES JIRSA
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Credential | D.D.S, M.S.
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Telephone | 928-778-2340
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number |
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License Number State |
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