Bonanza Square Dentistry LLC
Dentist, General Practice in Payson, AZ. Organization (NPI-2).
NPI number1104019918
StatusActive
Last updated in NPPESAug 24, 2007
Details
- NPI
- 1104019918
- Entity type
- Organization (NPI-2)
- Legal business name
- Bonanza Square Dentistry LLC
- Organization subpart
- No
- Enumeration date
- Aug 24, 2007
- Last updated
- Aug 24, 2007
Taxonomy and licenses
| Taxonomy code | Description | License | State | Primary |
|---|---|---|---|---|
| 1223G0001X | Dentist, General Practice | D5797 | AZ | Yes |
Practice location
200 W Frontier StSuite 5
Payson, AZ 85541
Phone 928-472-2500 · Fax 928-472-6699
Mailing address
200 W Frontier StSuite 5
Payson, AZ 85541
Phone 928-472-2500 · Fax 928-472-6699
Authorized official
Eldon Dwayne Jenkins
Owner
4802052476
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All 18 General Practice Dentistry providers in Payson · All 401 providers in Payson
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