Provider Demographics
NPI:1043214448
Name:KEYHANI, JALEH TINA (DDS)
Entity Type:Individual
Prefix:DR
First Name:JALEH
Middle Name:TINA
Last Name:KEYHANI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8350 E SUTTON DR
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-4929
Mailing Address - Country:US
Mailing Address - Phone:602-318-6795
Mailing Address - Fax:
Practice Address - Street 1:3150 N 7TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-5403
Practice Address - Country:US
Practice Address - Phone:602-277-3919
Practice Address - Fax:602-926-2216
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2020-01-30
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-23
Provider Licenses
StateLicense IDTaxonomies
AZD51601223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ529604Medicaid
AZU66271Medicare UPIN