Provider Demographics
NPI:1144832940
Name:KINGMAN DENTAL PROFESSIONALS, LLC
Entity type:Organization
Organization Name:KINGMAN DENTAL PROFESSIONALS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:LUNDGREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-295-9234
Mailing Address - Street 1:7205 E SOUTHERN AVE STE A-122
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-2790
Mailing Address - Country:US
Mailing Address - Phone:480-295-9234
Mailing Address - Fax:
Practice Address - Street 1:3775 N STOCKTON HILL RD
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-3219
Practice Address - Country:US
Practice Address - Phone:480-295-9234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-21
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental