Healthcare Provider Details

I. General information

NPI: 1831607845
Provider Name (Legal Business Name): JONATHAN SIMON BENSOUSSAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2018
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3443 N CENTRAL AVE STE 700
PHOENIX AZ
85012-2208
US

IV. Provider business mailing address

3443 N CENTRAL AVE STE 700
PHOENIX AZ
85012-2208
US

V. Phone/Fax

Practice location:
  • Phone: 602-242-2256
  • Fax:
Mailing address:
  • Phone: 602-242-2256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number010920
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: