Healthcare Provider Details

I. General information

NPI: 1265624332
Provider Name (Legal Business Name): MARVIN BLANE JACKSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2007
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 S MCCLINTOCK DR STE 111
TEMPE AZ
85283-3449
US

IV. Provider business mailing address

230 N FAIRGROUNDS RD
PRICE UT
84501-4205
US

V. Phone/Fax

Practice location:
  • Phone: 602-485-1588
  • Fax: 602-707-9740
Mailing address:
  • Phone: 435-637-2100
  • Fax: 435-612-0400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number6605138-9921
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD010196
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: