Provider Demographics
NPI:1487794798
Name:ON SITE DENTAL, PC
Entity type:Organization
Organization Name:ON SITE DENTAL, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:J
Authorized Official - Last Name:HISRICH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:928-567-1832
Mailing Address - Street 1:PO BOX 767
Mailing Address - Street 2:
Mailing Address - City:CAMP VERDE
Mailing Address - State:AZ
Mailing Address - Zip Code:86322-0767
Mailing Address - Country:US
Mailing Address - Phone:928-567-1832
Mailing Address - Fax:928-567-6500
Practice Address - Street 1:1996 DOUGS PARK RD
Practice Address - Street 2:
Practice Address - City:CAMP VERDE
Practice Address - State:AZ
Practice Address - Zip Code:86322
Practice Address - Country:US
Practice Address - Phone:928-567-1832
Practice Address - Fax:928-567-6500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMG2381Medicaid
AZ723157Medicaid