Healthcare Provider Details

I. General information

NPI: 1407788029
Provider Name (Legal Business Name): JET DENTAL ARIZONA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2026
Last Update Date: 05/29/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

865 E BASELINE RD # 1110
GILBERT AZ
85233-1246
US

IV. Provider business mailing address

865 E BASELINE RD # 1110
GILBERT AZ
85233-1246
US

V. Phone/Fax

Practice location:
  • Phone: 801-430-9262
  • Fax:
Mailing address:
  • Phone: 801-430-9262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DARRA THOMAS-DAVIS
Title or Position: PARALEGAL
Credential:
Phone: 972-369-2684