| Bonanza Square Dentistry Llc | |
|
200 W Frontier St Suite 5 Payson AZ 85541 | |
| (928) 472-2500 | |
| (928) 472-6699 |
| Full Name | Bonanza Square Dentistry Llc |
|---|---|
| Speciality | Dentist - General Practice |
| Location | 200 W Frontier St, Payson, Arizona |
| Authorized Official Name and Position | Eldon Dwayne Jenkins (OWNER) |
| Authorized Official Contact | 4802052476 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Bonanza Square Dentistry Llc 200 W Frontier St Suite 5 Payson AZ 85541 Ph: (928) 472-2500 | Bonanza Square Dentistry Llc 200 W Frontier St Suite 5 Payson AZ 85541 Ph: (928) 472-2500 |
| NPI Number | 1104019918 |
|---|---|
| Provider Enumeration Date | 08/24/2007 |
| Last Update Date | 08/24/2007 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1104019918 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223G0001X | Dentist - General Practice | D5797 (Arizona) | Primary |
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