Provider Demographics
NPI:1043466782
Name:16TH STREET DENTAL CARE
Entity type:Organization
Organization Name:16TH STREET DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:FREEZE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-782-3839
Mailing Address - Street 1:1325 W 16TH ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-4496
Mailing Address - Country:US
Mailing Address - Phone:928-782-3839
Mailing Address - Fax:928-329-9029
Practice Address - Street 1:1325 W 16TH ST
Practice Address - Street 2:SUITE 4
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-4496
Practice Address - Country:US
Practice Address - Phone:928-782-3839
Practice Address - Fax:928-329-9029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-13
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD72881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty