Provider Demographics
NPI:1407037807
Name:KINO DENTAL GROUP
Entity Type:Organization
Organization Name:KINO DENTAL GROUP
Other - Org Name:DBA FRONTIER DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:JENE
Authorized Official - Last Name:GOLD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:520-514-1883
Mailing Address - Street 1:4850 E. BROADWAY BLVD
Mailing Address - Street 2:FRONTIER DENTAL
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710
Mailing Address - Country:US
Mailing Address - Phone:520-514-1883
Mailing Address - Fax:520-514-1997
Practice Address - Street 1:4850 E. BROADWAY BLVD.
Practice Address - Street 2:FRONTIER DENTAL
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710
Practice Address - Country:US
Practice Address - Phone:520-514-1883
Practice Address - Fax:520-514-1997
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KINO DENTAL GROUP DBA FRONTIER DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-14
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223G0001X
AZ33981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ092578-006Medicaid