Provider Demographics
NPI:1841563095
Name:CASTLE DENTAL GROUP, PC
Entity type:Organization
Organization Name:CASTLE DENTAL GROUP, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:CASTLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:928-525-9263
Mailing Address - Street 1:751 CELILO
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-4007
Mailing Address - Country:US
Mailing Address - Phone:928-525-9263
Mailing Address - Fax:928-525-9338
Practice Address - Street 1:2700 S WOODLANDS VILLAGE BLVD STE 390
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-2981
Practice Address - Country:US
Practice Address - Phone:928-226-7654
Practice Address - Fax:928-226-7331
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CASTLE DENTAL GROUP, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-02-20
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2897261QD0000X, 332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental