Provider Demographics
NPI:1073382123
Name:FLAGSTAFF DENTISTRY 4 KIDS, PLLC
Entity Type:Organization
Organization Name:FLAGSTAFF DENTISTRY 4 KIDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:ZWICKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-866-8811
Mailing Address - Street 1:2801 N PLEASANT VIEW DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-3551
Mailing Address - Country:US
Mailing Address - Phone:928-463-2292
Mailing Address - Fax:928-460-7526
Practice Address - Street 1:2801 N PLEASANT VIEW DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-3551
Practice Address - Country:US
Practice Address - Phone:928-463-2292
Practice Address - Fax:928-460-7526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-29
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty