Provider Demographics
NPI:1952563132
Name:JUST FOR KIDS DENTISTRY BULLHEAD, PLLC
Entity Type:Organization
Organization Name:JUST FOR KIDS DENTISTRY BULLHEAD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:DICARLO
Authorized Official - Suffix:II
Authorized Official - Credentials:DMD
Authorized Official - Phone:928-718-7188
Mailing Address - Street 1:2580 HWY 95
Mailing Address - Street 2:STE. 101
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442
Mailing Address - Country:US
Mailing Address - Phone:928-758-9464
Mailing Address - Fax:928-758-9459
Practice Address - Street 1:2580 HWY 95
Practice Address - Street 2:STE. 101
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442
Practice Address - Country:US
Practice Address - Phone:928-758-9464
Practice Address - Fax:928-758-9459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-27
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD6061302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ983470Medicaid