Provider Demographics
NPI:1104055771
Name:SORENSEN, JARED MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:JARED
Middle Name:MICHAEL
Last Name:SORENSEN
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 1:6750 N 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-1127
Mailing Address - Country:US
Mailing Address - Phone:602-242-5741
Mailing Address - Fax:602-242-5742
Practice Address - Street 1:6750 N 19TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-1127
Practice Address - Country:US
Practice Address - Phone:602-242-5741
Practice Address - Fax:602-242-5742
Is Sole Proprietor?:No
Enumeration Date:2009-07-04
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZD0081581223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program