Provider Demographics
NPI:1649460221
Name:TRI-STATES DENTAL, INC.
Entity type:Organization
Organization Name:TRI-STATES DENTAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DOMINIC
Authorized Official - Middle Name:
Authorized Official - Last Name:DO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:928-704-0144
Mailing Address - Street 1:1518 SIERRA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-6069
Mailing Address - Country:US
Mailing Address - Phone:928-704-0144
Mailing Address - Fax:928-704-9791
Practice Address - Street 1:1518 SIERRA VISTA DR
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-6069
Practice Address - Country:US
Practice Address - Phone:928-704-0144
Practice Address - Fax:928-704-9791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-30
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV48171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ190343Medicaid