Healthcare Provider Details

I. General information

NPI: 1114355575
Provider Name (Legal Business Name): PHOENIX MAXILLOFACIAL TRAUMA ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2013
Last Update Date: 10/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5410 N SCOTTSDALE RD SUITE B-110
PARADISE VALLEY AZ
85253-5927
US

IV. Provider business mailing address

5410 N SCOTTSDALE RD SUITE B-110
PARADISE VALLEY AZ
85253-5927
US

V. Phone/Fax

Practice location:
  • Phone: 480-300-7152
  • Fax: 480-725-0228
Mailing address:
  • Phone: 480-300-7152
  • Fax: 480-725-0228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number47593
License Number StateAZ

VIII. Authorized Official

Name: NICOLAS PHILIPPE BEBEAU
Title or Position: OWNER
Credential: MD, DDS
Phone: 480-300-7152