Provider Demographics
NPI:1164689139
Name:PAGE DENTAL CENTER
Entity Type:Organization
Organization Name:PAGE DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:S
Authorized Official - Last Name:GIFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:928-645-3206
Mailing Address - Street 1:PO BOX 1956
Mailing Address - Street 2:112 SIXTH AVENUE
Mailing Address - City:PAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:86040-1956
Mailing Address - Country:US
Mailing Address - Phone:928-645-3206
Mailing Address - Fax:928-645-9139
Practice Address - Street 1:112 SIXTH AVENUE
Practice Address - Street 2:
Practice Address - City:PAGE
Practice Address - State:AZ
Practice Address - Zip Code:86040-1956
Practice Address - Country:US
Practice Address - Phone:928-645-3206
Practice Address - Fax:928-645-9139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-19
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ34401223G0001X
AZ54111223G0001X
AZ74271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ084004Medicaid
AZ283845Medicaid
AZ086274Medicaid