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General NPI Number Information
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NPI Number | 1942672118
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Entity Type | Organization
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Legal Business Name | OLD TOWN GENERAL DENTISTRY & DENTURE LAB
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Dates
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Enumeration Date | 10/27/2015
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Last Update Date | 10/27/2015
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Provider Practice Location Address
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Address Line | 542 N MAIN ST
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City | COTTONWOOD
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State | AZ
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Zip | 86326-3896
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Country | US
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Telephone | 928-634-8567
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Fax |
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Provider Business Mailing Address
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Address Line | 542 N MAIN ST
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City | COTTONWOOD
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State | AZ
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Zip | 86326-3896
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Country | US
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Telephone | 928-634-8567
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Fax |
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Authorized Official
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Title or Position | DENTIST/MEMBER
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Name | DR. JEFFREY C BLAIR
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Credential | DMD
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Telephone | 928-634-8567
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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 | D4038
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License Number State | AZ
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