Healthcare Provider Details

I. General information

NPI: 1043214448
Provider Name (Legal Business Name): JALEH TINA KEYHANI D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 01/30/2020
Certification Date: 01/30/2020
Deactivation Date: 03/16/2006
Reactivation Date: 03/23/2006

III. Provider practice location address

3150 N 7TH ST
PHOENIX AZ
85014-5403
US

IV. Provider business mailing address

8350 E SUTTON DR
SCOTTSDALE AZ
85260-4929
US

V. Phone/Fax

Practice location:
  • Phone: 602-277-3919
  • Fax: 602-926-2216
Mailing address:
  • Phone: 602-318-6795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD5160
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: