Healthcare Provider Details

I. General information

NPI: 1285432518
Provider Name (Legal Business Name): SURPRISE ENDO PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2025
Last Update Date: 03/04/2025
Certification Date: 03/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15294 W BROOKSIDE LN STE 100
SURPRISE AZ
85374-2446
US

IV. Provider business mailing address

15294 W BROOKSIDE LN STE 100
SURPRISE AZ
85374-2446
US

V. Phone/Fax

Practice location:
  • Phone: 623-376-7400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RYNE JACKSON
Title or Position: OWNER
Credential: DMD, MSD
Phone: 480-353-6476