Provider Demographics
NPI:1669949582
Name:RIATA VALLEY DENTAL GROUP
Entity type:Organization
Organization Name:RIATA VALLEY DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LEIGHANN
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-753-5069
Mailing Address - Street 1:1720 E BEVERLY AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3567
Mailing Address - Country:US
Mailing Address - Phone:928-753-5069
Mailing Address - Fax:
Practice Address - Street 1:1111 RIATA VALLEY RD STE 350
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3719
Practice Address - Country:US
Practice Address - Phone:928-757-9190
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-29
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty