Healthcare Provider Details

I. General information

NPI: 1427101104
Provider Name (Legal Business Name): TODD F JORGENSON D.M.D., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3048 E BASELINE RD SUITE 112
MESA AZ
85204-7286
US

IV. Provider business mailing address

3048 E BASELINE RD SUITE 112
MESA AZ
85204-7286
US

V. Phone/Fax

Practice location:
  • Phone: 480-558-4500
  • Fax:
Mailing address:
  • Phone: 480-558-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number5804
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: