Provider Demographics
NPI:1932354974
Name:JUST FOR KIDS DENTISTRY LAKE HAVASU
Entity Type:Organization
Organization Name:JUST FOR KIDS DENTISTRY LAKE HAVASU
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:A
Authorized Official - Last Name:DICARLO
Authorized Official - Suffix:II
Authorized Official - Credentials:DMD
Authorized Official - Phone:928-718-7188
Mailing Address - Street 1:80 ACOMA BLVD S
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-6925
Mailing Address - Country:US
Mailing Address - Phone:928-855-7717
Mailing Address - Fax:928-855-7718
Practice Address - Street 1:80 ACOMA BLVD S
Practice Address - Street 2:SUITE 102
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6925
Practice Address - Country:US
Practice Address - Phone:928-855-7717
Practice Address - Fax:928-855-7718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-18
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD6061122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty