Healthcare Provider Details

I. General information

NPI: 1013023928
Provider Name (Legal Business Name): AFFILIATED ORAL & MAXILLOFACIAL SURGEONS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

5750 W THUNDERBIRD H-850
GLENDALE AZ
85306
US

IV. Provider business mailing address

5750 W THUNDERBIRD H-850
GLENDALE AZ
85306
US

V. Phone/Fax

Practice location:
  • Phone: 602-938-0880
  • Fax: 602-547-0528
Mailing address:
  • Phone: 602-938-0880
  • Fax: 602-547-0528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2579
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number5950
License Number StateAZ

VIII. Authorized Official

Name: DR. CHARLES G BODE
Title or Position: ORAL SURGEON
Credential: DMD
Phone: 602-938-0880