Healthcare Provider Details

I. General information

NPI: 1205995719
Provider Name (Legal Business Name): EAST VALLEY ORAL SURGERY,PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 W RAY RD STE 14
CHANDLER AZ
85226-5940
US

IV. Provider business mailing address

3800 W RAY RD STE 14
CHANDLER AZ
85226-5940
US

V. Phone/Fax

Practice location:
  • Phone: 480-812-8200
  • Fax: 480-812-8522
Mailing address:
  • Phone: 480-812-8200
  • Fax: 480-812-8522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD6044
License Number StateAZ

VIII. Authorized Official

Name: DR. ERIC R ENGEL
Title or Position: OWNER
Credential: DDS,MD
Phone: 480-812-8200