Healthcare Provider Details

I. General information

NPI: 1528530284
Provider Name (Legal Business Name): AZ MAX SURGEONS PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2018
Last Update Date: 07/30/2021
Certification Date: 07/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6755 E SUPERSTITION SPRINGS BLVD STE 103
MESA AZ
85206-4375
US

IV. Provider business mailing address

6755 E SUPERSTITION SPRINGS BLVD STE 103
MESA AZ
85206-4375
US

V. Phone/Fax

Practice location:
  • Phone: 480-830-5866
  • Fax: 480-807-0606
Mailing address:
  • Phone: 480-830-5866
  • Fax: 480-807-0606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JILIAN PORTER
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 480-830-5866