Bonanza Square Dentistry LLC

NPI #1104019918 in Payson, Arizona

Provider Information

NPI Number: 1104019918
Entity Type: Organization
Organization Name: Bonanza Square Dentistry LLC
Primary Specialty: Dentist - General Practice
Enumeration Date: Aug 24, 2007
Last Updated: Aug 24, 2007

Practice Location

Address: 200 W FRONTIER ST
Address 2: SUITE 5
City: Payson
State: Arizona
ZIP Code: 85541
Phone: (928) 472-2500

Authorized Official

Name: MR. ELDON DWAYNE JENKINS, OWNER
Title: OWNER
Phone: (480) 205-2476

Specialties & Taxonomy Codes

Specialty	Taxonomy Code	Primary
Dentist - General Practice — General Practice	1223G0001X	Primary

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