Provider Demographics
NPI:1508684887
Name:CEDAR AVE FAMILY DENTISTRY LLC
Entity type:Organization
Organization Name:CEDAR AVE FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHITTENDEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:425-870-3325
Mailing Address - Street 1:2010 E CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-1621
Mailing Address - Country:US
Mailing Address - Phone:425-870-3325
Mailing Address - Fax:
Practice Address - Street 1:2010 E CEDAR AVE
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-1621
Practice Address - Country:US
Practice Address - Phone:928-774-3851
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-26
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1528551603OtherARIZONA
AZ1538783360OtherARIZONA