MEDICARE: LAKE HAVASU CITY VALLEY DENTAL ASSOCIATES PC

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		AZ

General Provider Information

NPI Number	:	1699792788
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE HAVASU CITY VALLEY DENTAL ASSOCIATES PC

Provider Business Mailing Address
First Line	:	1939 MCCULLOCH BLVD
Second Line	:	#2
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403
Country	:	US
Telephone Number	:	928-855-5041
Fax Number	:	928-855-2757

Provider Business Practice Location Address
First Line	:	1939 MCCULLOCH BLVD N
Second Line	:	STE 2
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-5652
Country	:	US
Telephone Number	:	928-855-5041
Fax Number	:	928-855-2757

Authorized Official
Title or Position	:	ADMINISTRATIVE DIRECTOR
Name	:	MRS. BETTY ANN HORN
Credential	:
Telephone Number	:	928-855-5041

Provider Enumeration Date	:	07/16/2006
Last Update Date	:	07/21/2022

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