Provider Demographics
NPI:1104119858
Name:JARJIS, LANA (RDH)
Entity type:Individual
Prefix:MRS
First Name:LANA
Middle Name:
Last Name:JARJIS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15182 N 75TH AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4722
Mailing Address - Country:US
Mailing Address - Phone:623-878-2400
Mailing Address - Fax:
Practice Address - Street 1:15182 N 75TH AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4722
Practice Address - Country:US
Practice Address - Phone:623-878-2400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-26
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5845124Q00000X
IL020010334124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist