Provider Demographics
NPI:1063897411
Name:HORIZON DENTAL GROUP PRESCOTT, LLC
Entity type:Organization
Organization Name:HORIZON DENTAL GROUP PRESCOTT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELCIE
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-925-6522
Mailing Address - Street 1:139 S MARINA ST
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86303-3830
Mailing Address - Country:US
Mailing Address - Phone:928-925-6522
Mailing Address - Fax:928-636-1164
Practice Address - Street 1:919 12TH PL
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-1433
Practice Address - Country:US
Practice Address - Phone:928-925-6522
Practice Address - Fax:928-636-1164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-28
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD84891223G0001X
AZD87531223G0001X
AZD56341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ824155Medicaid
AZ703042Medicaid
AZ731456Medicaid