Provider Demographics
NPI:1407322399
Name:KINGMAN DENTAL GROUP
Entity Type:Organization
Organization Name:KINGMAN DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LEIGHANN
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-753-5069
Mailing Address - Street 1:1730 E BEVERLY AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3500
Mailing Address - Country:US
Mailing Address - Phone:928-757-1707
Mailing Address - Fax:928-757-3070
Practice Address - Street 1:1730 E BEVERLY AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3500
Practice Address - Country:US
Practice Address - Phone:928-757-1707
Practice Address - Fax:928-757-3070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-17
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty