Provider Demographics
NPI:1235336009
Name:VALLEY DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:VALLEY DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:W
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:928-763-8111
Mailing Address - Street 1:1360 RAMAR RD
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-7146
Mailing Address - Country:US
Mailing Address - Phone:928-763-8111
Mailing Address - Fax:928-763-4137
Practice Address - Street 1:1360 RAMAR RD
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-7146
Practice Address - Country:US
Practice Address - Phone:928-763-8111
Practice Address - Fax:928-763-4137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ28331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty