Healthcare Provider Details

I. General information

NPI: 1902019607
Provider Name (Legal Business Name): JEFFREY BRENT SANDERS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7505 W. DEER VALLEY RD. SUITE 130
PEORIA AZ
85382
US

IV. Provider business mailing address

7505 W. DEER VALLEY RD. SUITE 130
PEORIA AZ
85382
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:
Title or Position:
Credential:
Phone: