Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | D008158 | AZ |
NPI | 1104055771 |
---|---|
Provider Name | Dr. Jared Michael Sorensen |
First Address | Phoenix, AZ 85015-1127 |
Second Address | Phoenix, AZ 85015-1127 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/07/2009 |
Last Update Date | 17/11/2020 |