Provider Demographics
NPI:1376009175
Name:JKA DENTAL PLLC
Entity Type:Organization
Organization Name:JKA DENTAL PLLC
Other - Org Name:EASTPORT DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VINH
Authorized Official - Middle Name:
Authorized Official - Last Name:HUYNH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:480-526-3664
Mailing Address - Street 1:1905 E MCKELLIPS RD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203-2865
Mailing Address - Country:US
Mailing Address - Phone:480-526-3664
Mailing Address - Fax:
Practice Address - Street 1:1905 E MCKELLIPS RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85203-2865
Practice Address - Country:US
Practice Address - Phone:480-649-1949
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-16
Last Update Date:2019-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1659659142OtherPPO AND HMO
AZ1376009175Medicaid
AZ1659659142Medicaid
AZ1376009175OtherPPO AND HMO