Provider Demographics
NPI:1912301425
Name:ARIZONA HAVASU BDM PAK LLC
Entity Type:Organization
Organization Name:ARIZONA HAVASU BDM PAK LLC
Other - Org Name:BRIDGE LAKE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INSURANCE DEPARTMENT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROLAND
Authorized Official - Middle Name:
Authorized Official - Last Name:PISCHINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-522-2028
Mailing Address - Street 1:2101 S JONES BLVD STE 140
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-3133
Mailing Address - Country:US
Mailing Address - Phone:702-522-2025
Mailing Address - Fax:702-990-8856
Practice Address - Street 1:1799 NORTH KIOWA BLVD
Practice Address - Street 2:UNIT 109
Practice Address - City:LAKE HAVASU
Practice Address - State:AZ
Practice Address - Zip Code:86403
Practice Address - Country:US
Practice Address - Phone:928-399-7711
Practice Address - Fax:928-399-7710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-13
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty