Healthcare Provider Details

I. General information

NPI: 1043541907
Provider Name (Legal Business Name): JEFFREY CRAIG WIGHT DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2010
Last Update Date: 06/10/2024
Certification Date: 06/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4135 S POWER RD STE 101
MESA AZ
85212-3625
US

IV. Provider business mailing address

4135 S POWER RD STE 101
MESA AZ
85212-3625
US

V. Phone/Fax

Practice location:
  • Phone: 480-588-2188
  • Fax: 480-588-2116
Mailing address:
  • Phone: 480-588-2188
  • Fax: 602-992-6604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number7838
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD07838
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberD07838
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code1223X2210X
TaxonomyOrofacial Pain Dentistry
License NumberD07838
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: