Provider Demographics
NPI:1891244281
Name:PRESCOTT PERIODONTICS & IMPLANT DENTISTRY, PLLC
Entity Type:Organization
Organization Name:PRESCOTT PERIODONTICS & IMPLANT DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PERIODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:JIRSA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:928-778-2340
Mailing Address - Street 1:1229 WILLOW CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1427
Mailing Address - Country:US
Mailing Address - Phone:928-778-2340
Mailing Address - Fax:928-778-3646
Practice Address - Street 1:1229 WILLOW CREEK RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1427
Practice Address - Country:US
Practice Address - Phone:928-778-2340
Practice Address - Fax:928-778-3646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-26
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty