Provider Demographics
NPI:1104019918
Name:BONANZA SQUARE DENTISTRY LLC
Entity Type:Organization
Organization Name:BONANZA SQUARE DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ELDON
Authorized Official - Middle Name:DWAYNE
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER
Authorized Official - Phone:480-205-2476
Mailing Address - Street 1:200 W FRONTIER ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:PAYSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85541
Mailing Address - Country:US
Mailing Address - Phone:928-472-2500
Mailing Address - Fax:928-472-6699
Practice Address - Street 1:200 W FRONTIER ST
Practice Address - Street 2:SUITE 5
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541
Practice Address - Country:US
Practice Address - Phone:928-472-2500
Practice Address - Fax:928-472-6699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-24
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD57971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty