MEDICARE: MONTEZUMA FAMILY DENTAL

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	:	1992171532
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MONTEZUMA FAMILY DENTAL

Provider Business Mailing Address
First Line	:	PO BOX 5682
Second Line	:
City	:	LAKE MONTEZUMA
State	:	AZ
Zip	:	86342-5682
Country	:	US
Telephone Number	:	928-202-4787
Fax Number	:	928-233-6904

Provider Business Practice Location Address
First Line	:	4283 N PIMA WAY
Second Line	:
City	:	LAKE MONTEZUMA
State	:	AZ
Zip	:	86342
Country	:	US
Telephone Number	:	928-202-4787
Fax Number	:	928-233-6904

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. RYAN CARTER
Credential	:	D.D.S
Telephone Number	:	928-202-4787

Provider Enumeration Date	:	08/18/2015
Last Update Date	:	08/18/2015

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Directions to “MONTEZUMA FAMILY DENTAL ” Practice Location

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