Healthcare Provider Details

I. General information

NPI: 1780069997
Provider Name (Legal Business Name): J BRENT SANDERS DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2015
Last Update Date: 07/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7505 W DEER VALLEY RD STE 130
PEORIA AZ
85382-2107
US

IV. Provider business mailing address

7505 W DEER VALLEY RD STE 130
PEORIA AZ
85382-2107
US

V. Phone/Fax

Practice location:
  • Phone: 623-572-7505
  • Fax: 623-572-7602
Mailing address:
  • Phone: 623-572-7505
  • Fax: 623-572-7602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number3208
License Number StateAZ

VIII. Authorized Official

Name: J BRENT SANDERS
Title or Position: DOCTOR
Credential:
Phone: 623-572-7505