1487158473 NPI number — JARED BENJAMIN TINKER DMD

Table of content: JARED BENJAMIN TINKER DMD (NPI 1487158473)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487158473 NPI number — JARED BENJAMIN TINKER DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TINKER
Provider First Name:
JARED
Provider Middle Name:
BENJAMIN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487158473
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/04/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/25/2018
NPI Reactivation Date:
04/05/2018

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3442 E TULSA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GILBERT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85295-3453
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-885-9864
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3592 S ATHERTON BLVD STE 107
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GILBERT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85297-7444
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-456-4038
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/22/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  D010531 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)