Provider Demographics
NPI:1093288334
Name:KKTZ DENTAL PLLC
Entity Type:Organization
Organization Name:KKTZ DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GAYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:JENNINGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-577-2533
Mailing Address - Street 1:5221 S HIGHWAY 95 STE 4
Mailing Address - Street 2:
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86426-9244
Mailing Address - Country:US
Mailing Address - Phone:928-577-2533
Mailing Address - Fax:928-577-2518
Practice Address - Street 1:5221 S HIGHWAY 95 STE 4
Practice Address - Street 2:
Practice Address - City:FORT MOHAVE
Practice Address - State:AZ
Practice Address - Zip Code:86426-9244
Practice Address - Country:US
Practice Address - Phone:928-577-2533
Practice Address - Fax:928-577-2518
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KKTZ DENTAL PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-01-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty