Provider Demographics
NPI:1588316806
Name:CL VALLEY DENTAL
Entity type:Organization
Organization Name:CL VALLEY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RDH
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:AVERLAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-788-3359
Mailing Address - Street 1:5677 S HIGHWAY 95
Mailing Address - Street 2:
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86426-6049
Mailing Address - Country:US
Mailing Address - Phone:928-788-3359
Mailing Address - Fax:928-768-6412
Practice Address - Street 1:5677 S HIGHWAY 95
Practice Address - Street 2:
Practice Address - City:FORT MOHAVE
Practice Address - State:AZ
Practice Address - Zip Code:86426-6049
Practice Address - Country:US
Practice Address - Phone:928-788-3359
Practice Address - Fax:928-768-6412
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CL VALLEY DENTAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-01-19
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental