Provider Demographics
NPI:1366914012
Name:BLUE RIDGE FAMILY DENTISTRY, PC
Entity type:Organization
Organization Name:BLUE RIDGE FAMILY DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, BRFD, PC
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HANRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:928-367-4466
Mailing Address - Street 1:PO BOX 3768
Mailing Address - Street 2:
Mailing Address - City:PINETOP
Mailing Address - State:AZ
Mailing Address - Zip Code:85935-3768
Mailing Address - Country:US
Mailing Address - Phone:928-367-4466
Mailing Address - Fax:
Practice Address - Street 1:1450 E WHITE MOUNTAIN BLVD STE A
Practice Address - Street 2:
Practice Address - City:PINETOP
Practice Address - State:AZ
Practice Address - Zip Code:85935-7091
Practice Address - Country:US
Practice Address - Phone:928-367-4466
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental