Provider Demographics
NPI:1063983245
Name:RUSTIC MOUNTAIN DENTISTRY
Entity type:Organization
Organization Name:RUSTIC MOUNTAIN DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:HOUSTON
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:928-457-0758
Mailing Address - Street 1:PO BOX 1550
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:AZ
Mailing Address - Zip Code:85939-1550
Mailing Address - Country:US
Mailing Address - Phone:928-457-0758
Mailing Address - Fax:928-457-0821
Practice Address - Street 1:606 N MAIN STREET
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:AZ
Practice Address - Zip Code:85939-8593
Practice Address - Country:US
Practice Address - Phone:928-457-0758
Practice Address - Fax:928-457-0821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental