Healthcare Provider Details

I. General information

NPI: 1487349411
Provider Name (Legal Business Name): PHOENIX FACE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2023
Last Update Date: 04/06/2023
Certification Date: 04/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5757 W THUNDERBIRD RD STE W301
GLENDALE AZ
85306-5606
US

IV. Provider business mailing address

PO BOX 73152
PHOENIX AZ
85050-1036
US

V. Phone/Fax

Practice location:
  • Phone: 602-938-3777
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: DR. TROY LAM
Title or Position: MEMBER
Credential: DDS, MD
Phone: 315-416-0678