MEDICARE: DR. JONATHAN LANE SANDERS DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	D010810	AZ

General Provider Information

NPI Number	:	1720692502
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN LANE SANDERS DMD

Provider Business Mailing Address
First Line	:	2716 E FAIRFIELD CIR
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85213-5300
Country	:	US
Telephone Number	:	480-404-5909
Fax Number	:

Provider Business Practice Location Address
First Line	:	1801 E SOUTHERN AVE
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85204-5258
Country	:	US
Telephone Number	:	480-892-9000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2020
Last Update Date	:	08/31/2020

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