Provider Demographics
NPI:1861012023
Name:PASEO RANCH PEDIATRIC DENTISTRY AND ORTHODONTICS
Entity Type:Organization
Organization Name:PASEO RANCH PEDIATRIC DENTISTRY AND ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST AND OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:623-606-2217
Mailing Address - Street 1:6677 W THUNDERBIRD RD STE A124
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-3710
Mailing Address - Country:US
Mailing Address - Phone:623-223-9677
Mailing Address - Fax:
Practice Address - Street 1:6677 W THUNDERBIRD RD STE A124
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-3710
Practice Address - Country:US
Practice Address - Phone:623-223-9677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-17
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ200173Medicaid