MEDICARE: PLEASANT VALLEY DENTAL CARE, P.C.

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	261QD0000X	Dental Clinic/Center	D5495	AZ

General Provider Information

NPI Number	:	1538323266
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PLEASANT VALLEY DENTAL CARE, P.C.

Provider Business Mailing Address
First Line	:	2178 MCCULLOCH BLVD N STE 14
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-6869
Country	:	US
Telephone Number	:	928-855-5159
Fax Number	:

Provider Business Practice Location Address
First Line	:	2178 MCCULLOCH BLVD N STE 14
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-6869
Country	:	US
Telephone Number	:	928-855-5159
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KEVIN J CEBULA
Credential	:	D.D.S.
Telephone Number	:	928-855-5159

Provider Enumeration Date	:	07/11/2008
Last Update Date	:	07/11/2008

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