Provider Demographics
NPI:1699792788
Name:LAKE HAVASU CITY VALLEY DENTAL ASSOCIATES PC
Entity type:Organization
Organization Name:LAKE HAVASU CITY VALLEY DENTAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-855-5041
Mailing Address - Street 1:1939 MCCULLOCH BLVD
Mailing Address - Street 2:#2
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403
Mailing Address - Country:US
Mailing Address - Phone:928-855-5041
Mailing Address - Fax:928-855-2757
Practice Address - Street 1:1939 MCCULLOCH BLVD N
Practice Address - Street 2:STE 2
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5652
Practice Address - Country:US
Practice Address - Phone:928-855-5041
Practice Address - Fax:928-855-2757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty