Healthcare Provider Details

I. General information

NPI: 1104119858
Provider Name (Legal Business Name): LANA JARJIS RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2011
Last Update Date: 05/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15182 N 75TH AVE SUITE 120
PEORIA AZ
85381-4722
US

IV. Provider business mailing address

15182 N 75TH AVE SUITE 120
PEORIA AZ
85381-4722
US

V. Phone/Fax

Practice location:
  • Phone: 623-878-2400
  • Fax:
Mailing address:
  • Phone: 623-878-2400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number5845
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number020010334
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: