Provider Demographics
NPI:1265608160
Name:YUMA FAMILY DENTAL, P.C.
Entity type:Organization
Organization Name:YUMA FAMILY DENTAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:BROCK
Authorized Official - Middle Name:J
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:970-848-5777
Mailing Address - Street 1:PO BOX 402
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:CO
Mailing Address - Zip Code:80759-0402
Mailing Address - Country:US
Mailing Address - Phone:970-848-5777
Mailing Address - Fax:970-848-2382
Practice Address - Street 1:900 S ASH ST
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:CO
Practice Address - Zip Code:80759
Practice Address - Country:US
Practice Address - Phone:970-848-5777
Practice Address - Fax:970-848-2382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-01
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental