Provider Demographics
NPI:1831554930
Name:DENTAL SPECIALISTS OF NW ARIZONA
Entity type:Organization
Organization Name:DENTAL SPECIALISTS OF NW ARIZONA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ENDODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAVENE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:928-854-5551
Mailing Address - Street 1:2152 MCCULLOCH BLVD N STE C
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-6805
Mailing Address - Country:US
Mailing Address - Phone:928-854-5551
Mailing Address - Fax:
Practice Address - Street 1:2152 MCCULLOCH BLVD N STE C
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6805
Practice Address - Country:US
Practice Address - Phone:928-854-5551
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-16
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ87931223E0200X
AZ88231223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty