Organization
TRI-STATES DENTAL, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DOMINIC DO D.D.S. (CFO)
(928) 704-0144
Entity
Organization
Contact information
Practice address
1518 SIERRA VISTA DR, BULLHEAD CITY, AZ 86442-6069
(928) 704-0144
(928) 704-9791
Mailing address
1518 SIERRA VISTA DR, BULLHEAD CITY, AZ 86442-6069
(928) 704-0144
(928) 704-9791
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
4817
NV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
190343
—
AZ
Enumeration date
07/30/2007
Last updated
07/30/2007
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