Bonanza Square Dentistry LLC
Organization Active NPI General Practice Dentistry · Payson, AZ
NPI 1104019918 · NPPES record last updated Aug 24, 2007
Key facts
- NPI
- 1104019918
- Entity type
- Organization (NPI type 2)
- Primary specialty
- General Practice Dentistry 1223G0001X
- License
- D5797 (AZ)
- Legal business name
- BONANZA SQUARE DENTISTRY LLC
- Practice address
- 200 W Frontier St
Suite 5
Payson, AZ 85541 - Phone
- (928) 472-2500
- Fax
- (928) 472-6699
- NPI assigned
- Aug 24, 2007
- Organization subpart
- No
Authorized official
- Name
- Mr. Eldon Dwayne Jenkins, OWNER
- Title
- Owner
- Phone
- (480) 205-2476
Practitioners 1
National Provider Directory
Locations
200 W Frontier St
Ste 5
Payson, AZ 85541
Phone (928) 472-2500
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry |
1223G0001X | D5797 | AZ | Yes |
Addresses
Primary practice location
200 W Frontier St
Suite 5
Payson, AZ 85541
Mailing address
200 W Frontier St
Suite 5
Payson, AZ 85541
Phone (928) 472-2500
Other providers in Payson, AZ
- BHSM Rehabilitation, LLC
- William Raymond Blackmore
- Lisa Marie Blasko
- Tyri Norman Blondal
- Sheila Eva Bloomquist
- Cynthia D Booth
- Steven Nicholas Booth
- Gerald Bossert
- Bruce Boushon
- Robin Bramble
All providers in Payson, AZ · General Practice Dentistry in Arizona
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 24, 2007. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.