MEDICARE: DR. JONATHAN BRUCE BARNES D.M.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223E0200X	Endodontics	D009064	AZ
2	1223G0001X	General Practice Dentistry	8350105-9921	UT
3	390200000X	Student in an Organized Health Care Education/Training Program
4	1223E0200X	Endodontics	D9064	AZ

General Provider Information

NPI Number	:	1750655627
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN BRUCE BARNES D.M.D

Provider Business Mailing Address
First Line	:	1630 S STAPLEY DR STE 208
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85204-6659
Country	:	US
Telephone Number	:	480-775-2656
Fax Number	:

Provider Business Practice Location Address
First Line	:	1630 S STAPLEY DR STE 208
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85204-6659
Country	:	US
Telephone Number	:	480-775-2656
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/23/2012
Last Update Date	:	07/21/2022

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