Provider Demographics
NPI:1649342510
Name:RIO COLORADO DENTAL INC
Entity type:Organization
Organization Name:RIO COLORADO DENTAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:BROCK
Authorized Official - Last Name:LAMB
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:928-763-2515
Mailing Address - Street 1:1467 PALMA ROAD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442
Mailing Address - Country:US
Mailing Address - Phone:928-763-2515
Mailing Address - Fax:928-758-4267
Practice Address - Street 1:1467 PALMA ROAD
Practice Address - Street 2:SUITE 3
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442
Practice Address - Country:US
Practice Address - Phone:928-763-2515
Practice Address - Fax:928-758-4267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2092122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty