Provider Demographics
NPI:1639783749
Name:PRESCOTT VALLEY ENDODONTIC ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:PRESCOTT VALLEY ENDODONTIC ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:OHLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-771-1640
Mailing Address - Street 1:1658 OAKLAWN DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-1110
Mailing Address - Country:US
Mailing Address - Phone:928-771-1640
Mailing Address - Fax:928-771-1640
Practice Address - Street 1:8053 E FLORENTINE RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-9423
Practice Address - Country:US
Practice Address - Phone:928-771-1640
Practice Address - Fax:928-771-1640
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRESCOTT ENDODONTIC ASSOCIATES PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-09-04
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty