Healthcare Provider Details

I. General information

NPI: 1407560675
Provider Name (Legal Business Name): RAE LAKES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2023
Last Update Date: 01/11/2023
Certification Date: 12/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3317 S HIGLEY RD
GILBERT AZ
85297-5436
US

IV. Provider business mailing address

1327 S NIELSON ST
GILBERT AZ
85296-4265
US

V. Phone/Fax

Practice location:
  • Phone: 480-868-1864
  • Fax:
Mailing address:
  • Phone: 480-868-1864
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JONATHON EDWARDS
Title or Position: OWNER
Credential: DMD
Phone: 480-868-1864