MEDICARE: KKTZ DENTAL PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1093288334
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KKTZ DENTAL PLLC

Provider Business Mailing Address
First Line	:	5221 S HIGHWAY 95 STE 4
Second Line	:
City	:	FORT MOHAVE
State	:	AZ
Zip	:	86426-9244
Country	:	US
Telephone Number	:	928-577-2533
Fax Number	:	928-577-2518

Provider Business Practice Location Address
First Line	:	5221 S HIGHWAY 95 STE 4
Second Line	:
City	:	FORT MOHAVE
State	:	AZ
Zip	:	86426-9244
Country	:	US
Telephone Number	:	928-577-2533
Fax Number	:	928-577-2518

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	GAYLE JENNINGS
Credential	:
Telephone Number	:	928-577-2533

Provider Enumeration Date	:	01/09/2019
Last Update Date	:	01/09/2019

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Directions to “KKTZ DENTAL PLLC ” Practice Location

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