Provider Demographics
NPI:1205445749
Name:FAMILY DENTAL PHOENIX
Entity type:Organization
Organization Name:FAMILY DENTAL PHOENIX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:BLANE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:435-637-2100
Mailing Address - Street 1:2401 W GLENDALE AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-7621
Mailing Address - Country:US
Mailing Address - Phone:602-864-1119
Mailing Address - Fax:
Practice Address - Street 1:2401 W GLENDALE AVE STE 102
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-7621
Practice Address - Country:US
Practice Address - Phone:602-864-1119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-30
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ586868Medicaid