=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043214448
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JALEH TINA KEYHANI D.D.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2005
-----------------------------------------------------
Last Update Date | 01/30/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3150 N 7TH ST
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85014-5403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-277-3919
-----------------------------------------------------
Fax | 602-926-2216
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8350 E SUTTON DR
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85260-4929
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-318-6795
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | D5160
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------