Provider Demographics
NPI:1407392590
Name:LAKE POWELL DENTAL CENTER, PC
Entity Type:Organization
Organization Name:LAKE POWELL DENTAL CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
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:928-645-2505
Mailing Address - Street 1:436 VISTA
Mailing Address - Street 2:
Mailing Address - City:PAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:86040-1956
Mailing Address - Country:US
Mailing Address - Phone:928-645-2505
Mailing Address - Fax:928-645-6820
Practice Address - Street 1:436 VISTA AVENUE
Practice Address - Street 2:BOX 1956
Practice Address - City:PAGE
Practice Address - State:AZ
Practice Address - Zip Code:86040
Practice Address - Country:US
Practice Address - Phone:928-645-2505
Practice Address - Fax:928-645-6820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-12
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2639122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty