Provider Demographics
NPI:1942361381
Name:SPARKS, JERRY PRESTON (DDS)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:PRESTON
Last Name:SPARKS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10565 N TATUM BLVD STE B110
Mailing Address - Street 2:
Mailing Address - City:PARADISE VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85253-1095
Mailing Address - Country:US
Mailing Address - Phone:480-998-2300
Mailing Address - Fax:
Practice Address - Street 1:10565 N TATUM BLVD STE B110
Practice Address - Street 2:
Practice Address - City:PARADISE VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85253-1095
Practice Address - Country:US
Practice Address - Phone:480-998-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ22231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice