Provider Demographics
NPI:1700222916
Name:CHANDLER MODERN DENTISTRY AND ORTHODONTICS, LLP
Entity Type:Organization
Organization Name:CHANDLER MODERN DENTISTRY AND ORTHODONTICS, LLP
Other - Org Name:CHANDLER MODERN DENTISTRY AND ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TYSON
Authorized Official - Middle Name:M
Authorized Official - Last Name:JOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:480-792-1543
Mailing Address - Street 1:PO BOX 920050
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75392-0050
Mailing Address - Country:US
Mailing Address - Phone:714-845-8890
Mailing Address - Fax:714-845-8803
Practice Address - Street 1:2875 W RAY RD STE 16
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-3619
Practice Address - Country:US
Practice Address - Phone:480-792-1543
Practice Address - Fax:480-792-1544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-14
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty