Provider Demographics
NPI:1427411255
Name:FLAGSTAFF DENTISTRY 4 KIDS, PLLC
Entity Type:Organization
Organization Name:FLAGSTAFF DENTISTRY 4 KIDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWENER
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:480-607-9999
Mailing Address - Street 1:710 N BEAVER ST
Mailing Address - Street 2:BLDG 2
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3100
Mailing Address - Country:US
Mailing Address - Phone:928-773-8571
Mailing Address - Fax:928-255-4814
Practice Address - Street 1:710 N BEAVER ST
Practice Address - Street 2:BLDG 2
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3100
Practice Address - Country:US
Practice Address - Phone:928-773-8571
Practice Address - Fax:928-255-4814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-30
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD049641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty