Provider Demographics
NPI:1821166760
Name:ULDRIKSON, BARRY J (DDS)
Entity Type:Individual
Prefix:DR
First Name:BARRY
Middle Name:J
Last Name:ULDRIKSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 RIATA VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409
Mailing Address - Country:US
Mailing Address - Phone:928-692-9394
Mailing Address - Fax:928-692-9399
Practice Address - Street 1:1101 RIATA VALLEY RD.
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409
Practice Address - Country:US
Practice Address - Phone:928-692-9394
Practice Address - Fax:928-692-9399
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ31191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ580937-03Medicaid
AZD3119OtherDELTA DENTAL
AZAZ0471610OtherBLUECROSS BLUESHIELD