Provider Demographics
NPI:1851554240
Name:JUST FOR KIDS DENTISTRY KINGMAN PLLC
Entity Type:Organization
Organization Name:JUST FOR KIDS DENTISTRY KINGMAN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:DICARLO
Authorized Official - Suffix:II
Authorized Official - Credentials:DMD
Authorized Official - Phone:928-718-7188
Mailing Address - Street 1:2401 STOCKTON HILL RD
Mailing Address - Street 2:STE 1
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401
Mailing Address - Country:US
Mailing Address - Phone:928-718-7188
Mailing Address - Fax:928-718-7189
Practice Address - Street 1:2401 STOCKTON HILL RD
Practice Address - Street 2:STE 1
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-4189
Practice Address - Country:US
Practice Address - Phone:928-718-7188
Practice Address - Fax:928-718-7189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-07
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD6061302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ983470Medicaid