Healthcare Provider Details

I. General information

NPI: 1023206430
Provider Name (Legal Business Name): JIMMY RAY PATTEN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2007
Last Update Date: 10/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 E INDIAN SCHOOL RD
PHOENIX AZ
85012-1839
US

IV. Provider business mailing address

650 E INDIAN SCHOOL RD
PHOENIX AZ
85012-1839
US

V. Phone/Fax

Practice location:
  • Phone: 602-222-6424
  • Fax:
Mailing address:
  • Phone: 602-222-6424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD6040
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: