Provider Demographics
NPI:1265085567
Name:THE RIVER'S EDGE DENTAL
Entity type:Organization
Organization Name:THE RIVER'S EDGE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:BLANE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:435-637-2100
Mailing Address - Street 1:1185 N ARIZONA BLVD
Mailing Address - Street 2:
Mailing Address - City:COOLIDGE
Mailing Address - State:AZ
Mailing Address - Zip Code:85128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1185 N ARIZONA BLVD
Practice Address - Street 2:
Practice Address - City:COOLIDGE
Practice Address - State:AZ
Practice Address - Zip Code:85128
Practice Address - Country:US
Practice Address - Phone:435-518-3343
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-17
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty