Provider Demographics
NPI:1699959064
Name:TUCSON MOUNTAIN DENTAL
Entity type:Organization
Organization Name:TUCSON MOUNTAIN DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:HUCKABEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:520-514-7400
Mailing Address - Street 1:5723 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-2401
Mailing Address - Country:US
Mailing Address - Phone:520-514-7400
Mailing Address - Fax:520-514-7403
Practice Address - Street 1:5723 E 5TH ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-2401
Practice Address - Country:US
Practice Address - Phone:520-514-7400
Practice Address - Fax:520-514-7403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-20
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty