Provider Demographics
NPI:1013272624
Name:PEARSON, JEFFREY T
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:T
Last Name:PEARSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7595 W WASHINGTON AVE STE 170
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-4345
Mailing Address - Country:US
Mailing Address - Phone:702-444-2494
Mailing Address - Fax:
Practice Address - Street 1:7595 W WASHINGTON AVE STE 170
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-4345
Practice Address - Country:US
Practice Address - Phone:702-444-2494
Practice Address - Fax:702-505-4448
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-10
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD008428122300000X
NV73701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1134345937Medicaid
AZ670703Medicaid