Healthcare Provider Details

I. General information

NPI: 1003872680
Provider Name (Legal Business Name): NORTH STAPELY DENTAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 N STAPLEY DR
MESA AZ
85203-8030
US

IV. Provider business mailing address

335 N STAPLEY DR
MESA AZ
85203-8030
US

V. Phone/Fax

Practice location:
  • Phone: 480-964-2662
  • Fax: 480-649-9813
Mailing address:
  • Phone: 480-964-2662
  • Fax: 480-649-9813

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5252
License Number StateAZ

VIII. Authorized Official

Name: DR. CHET L JENKINS
Title or Position: OWNER
Credential: D.D.S.
Phone: 480-792-6880