Provider Demographics
NPI:1962733600
Name:ANASAZI DENTURE CLINIC, LLC
Entity type:Organization
Organization Name:ANASAZI DENTURE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CAIN
Authorized Official - Suffix:
Authorized Official - Credentials:CDT, LD, DN
Authorized Official - Phone:480-471-9560
Mailing Address - Street 1:P.O.BOX 111
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:WA
Mailing Address - Zip Code:99328
Mailing Address - Country:US
Mailing Address - Phone:480-650-4234
Mailing Address - Fax:480-471-3089
Practice Address - Street 1:18425 E STIRRUP LN
Practice Address - Street 2:
Practice Address - City:RIO VERDE
Practice Address - State:AZ
Practice Address - Zip Code:85263-7114
Practice Address - Country:US
Practice Address - Phone:480-471-9560
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-20
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADN60082396261QD0000X, 302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No302F00000XManaged Care OrganizationsExclusive Provider Organization