Healthcare Provider Details

I. General information

NPI: 1619707049
Provider Name (Legal Business Name): SOUTHWEST OROFACIAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2024
Last Update Date: 05/27/2025
Certification Date: 05/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6116 E ARBOR AVE STE 110
MESA AZ
85206-6103
US

IV. Provider business mailing address

10214 N TATUM BLVD STE A1100
PHOENIX AZ
85028-4243
US

V. Phone/Fax

Practice location:
  • Phone: 602-992-1486
  • Fax: 602-992-6604
Mailing address:
  • Phone: 602-992-1486
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223X2210X
TaxonomyOrofacial Pain Dentistry
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: THERESE GARVEY
Title or Position: OWNER
Credential:
Phone: 602-992-1486