Healthcare Provider Details

I. General information

NPI: 1902566896
Provider Name (Legal Business Name): TN DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2021
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
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

250 N FAIRGROUNDS RD STE 1
PRICE UT
84501-4201
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 TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: MARVIN BLANE JACKSON
Title or Position: DENTIST/ OWNER
Credential: DDS
Phone: 602-485-1588