Provider Demographics
NPI:1831607845
Name:BENSOUSSAN, JONATHAN SIMON (DDS)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:SIMON
Last Name:BENSOUSSAN
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 1:3443 N CENTRAL AVE STE 700
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2208
Mailing Address - Country:US
Mailing Address - Phone:602-242-2256
Mailing Address - Fax:
Practice Address - Street 1:3443 N CENTRAL AVE STE 700
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-2208
Practice Address - Country:US
Practice Address - Phone:602-242-2256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-12
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0109201223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty