Provider Demographics
NPI:1699970681
Name:FLAGSTAFF FAMILY DENTAL CENTER PLLC
Entity type:Organization
Organization Name:FLAGSTAFF FAMILY DENTAL CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:MCLEOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-290-6181
Mailing Address - Street 1:11550 E IRVINGTON RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85747
Mailing Address - Country:US
Mailing Address - Phone:520-290-6101
Mailing Address - Fax:520-290-6182
Practice Address - Street 1:2615 N 4TH ST
Practice Address - Street 2:SUITE 6
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004
Practice Address - Country:US
Practice Address - Phone:928-774-4761
Practice Address - Fax:928-773-9589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-19
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty