Provider Demographics
NPI:1932799053
Name:WILD WEST KIDS DENTAL BULLHEAD
Entity type:Organization
Organization Name:WILD WEST KIDS DENTAL BULLHEAD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:A
Authorized Official - Last Name:DICARLO
Authorized Official - Suffix:II
Authorized Official - Credentials:DMD
Authorized Official - Phone:928-718-7188
Mailing Address - Street 1:2401 N STOCKTON HILL RD STE 1
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-4189
Mailing Address - Country:US
Mailing Address - Phone:928-718-7188
Mailing Address - Fax:
Practice Address - Street 1:2401 MIRACLE MILE
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-7311
Practice Address - Country:US
Practice Address - Phone:928-704-5573
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-22
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty