Provider Demographics
NPI:1639192545
Name:PEARSON, JERRY R (DMD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:R
Last Name:PEARSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8104 N. 110TH PLACE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020
Mailing Address - Country:US
Mailing Address - Phone:623-434-9343
Mailing Address - Fax:623-321-6268
Practice Address - Street 1:1904 W PARKSIDE LN
Practice Address - Street 2:SUITE 201
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-1228
Practice Address - Country:US
Practice Address - Phone:623-434-9343
Practice Address - Fax:623-321-6268
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD51041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ612938Medicaid