Provider Demographics
NPI:1669774964
Name:FRONTIER DENTAL ARTS
Entity type:Organization
Organization Name:FRONTIER DENTAL ARTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:DIQUATTRO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:928-474-5231
Mailing Address - Street 1:704 S MEADOW ST
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85541-5341
Mailing Address - Country:US
Mailing Address - Phone:928-474-5231
Mailing Address - Fax:928-474-7448
Practice Address - Street 1:704 S MEADOW ST
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541-5341
Practice Address - Country:US
Practice Address - Phone:928-474-5231
Practice Address - Fax:928-474-7448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-19
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD75581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty