Organization
FAMILY DENTAL PHOENIX
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MARVIN BLANE JACKSON DDS (DDS)
(435) 637-2100
Entity
Organization
Contact information
Practice address
2401 W GLENDALE AVE STE 102, PHOENIX, AZ 85021-7621
(602) 864-1119
Mailing address
2401 W GLENDALE AVE STE 102, PHOENIX, AZ 85021-7621
(602) 864-1119
Taxonomy
Speciality
Code
Description
License number
State
261QD0000X
Dental Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
586868
—
AZ
Enumeration date
07/30/2020
Last updated
07/30/2020
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