Provider Demographics
NPI:1447399233
Name:PEDIATRIC DENTISTRY OF YUMA, INC.
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY OF YUMA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:CULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:928-329-9565
Mailing Address - Street 1:2359 S 22ND DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-8871
Mailing Address - Country:US
Mailing Address - Phone:928-329-9565
Mailing Address - Fax:928-783-0669
Practice Address - Street 1:2359 S 22ND DR
Practice Address - Street 2:SUITE 1
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-8871
Practice Address - Country:US
Practice Address - Phone:928-329-9565
Practice Address - Fax:928-783-0669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ41111223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty