Healthcare Provider Details

I. General information

NPI: 1073015517
Provider Name (Legal Business Name): JUSTIN VANCE SORENSEN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2018
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5058 E SOUTHERN AVE STE 101
MESA AZ
85206-2771
US

IV. Provider business mailing address

3764 E INDIGO BAY CT
GILBERT AZ
85234-0030
US

V. Phone/Fax

Practice location:
  • Phone: 480-325-7500
  • Fax:
Mailing address:
  • Phone: 928-322-2481
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD012643
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: