Provider Demographics
NPI:1043471493
Name:TRICITY DENTAL
Entity type:Organization
Organization Name:TRICITY DENTAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:JUAN
Authorized Official - Last Name:WULFF
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:928-445-3181
Mailing Address - Street 1:1000 WILLOW CREEK RD
Mailing Address - Street 2:SUITE H
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1645
Mailing Address - Country:US
Mailing Address - Phone:928-445-3181
Mailing Address - Fax:928-445-5797
Practice Address - Street 1:1000 WILLOW CREEK RD
Practice Address - Street 2:SUITE H
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1645
Practice Address - Country:US
Practice Address - Phone:928-445-3181
Practice Address - Fax:928-445-5797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-18
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD3674261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental