Provider Demographics
NPI:1902566896
Name:TN DENTISTRY
Entity Type:Organization
Organization Name:TN DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:BLANE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:602-485-1588
Mailing Address - Street 1:250 N FAIRGROUNDS RD STE 1
Mailing Address - Street 2:
Mailing Address - City:PRICE
Mailing Address - State:UT
Mailing Address - Zip Code:84501-4201
Mailing Address - Country:US
Mailing Address - Phone:435-637-2100
Mailing Address - Fax:435-612-0400
Practice Address - Street 1:4550 E BELL RD STE 102
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-9342
Practice Address - Country:US
Practice Address - Phone:602-485-1588
Practice Address - Fax:602-707-9740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-20
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty