Provider Demographics
NPI:1114462330
Name:SURPRISE PEDIATRIC DENTISTRY, PC
Entity Type:Organization
Organization Name:SURPRISE PEDIATRIC DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATHEW
Authorized Official - Middle Name:O
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:801-656-7978
Mailing Address - Street 1:15331 W BELL RD
Mailing Address - Street 2:SUITE #112
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-4102
Mailing Address - Country:US
Mailing Address - Phone:602-730-6481
Mailing Address - Fax:602-730-6482
Practice Address - Street 1:15331 W BELL RD
Practice Address - Street 2:SUITE #112
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-4102
Practice Address - Country:US
Practice Address - Phone:602-730-6481
Practice Address - Fax:602-730-6482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-23
Last Update Date:2016-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD008930261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ200173Medicaid