MEDICARE: DR. JACK WEISBOND 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	D011076	AZ

General Provider Information

NPI Number	:	1851962906
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACK WEISBOND DMD

Provider Business Mailing Address
First Line	:	110 E GREENWAY PKWY APT 2105
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85022-2551
Country	:	US
Telephone Number	:	847-444-9153
Fax Number	:

Provider Business Practice Location Address
First Line	:	7708 W BELL RD STE 103
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85308-8741
Country	:	US
Telephone Number	:	623-734-1506
Fax Number	:

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

Provider Enumeration Date	:	07/08/2021
Last Update Date	:	07/08/2021

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