Provider Demographics
NPI:1992037857
Name:VERDE DENTAL CARE, LLC
Entity Type:Organization
Organization Name:VERDE DENTAL CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:A
Authorized Official - Last Name:PETTERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:928-567-5249
Mailing Address - Street 1:PO BOX 788
Mailing Address - Street 2:
Mailing Address - City:CAMP VERDE
Mailing Address - State:AZ
Mailing Address - Zip Code:86322-0788
Mailing Address - Country:US
Mailing Address - Phone:928-567-5249
Mailing Address - Fax:928-567-0430
Practice Address - Street 1:522 W FINNIE FLATS RD
Practice Address - Street 2:STE J
Practice Address - City:CAMP VERDE
Practice Address - State:AZ
Practice Address - Zip Code:86322-7265
Practice Address - Country:US
Practice Address - Phone:928-567-5249
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-03
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD30891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty