Healthcare Provider Details

I. General information

NPI: 1497265516
Provider Name (Legal Business Name): PEORIA ORAL & IMPLANT SURGERY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2017
Last Update Date: 03/24/2022
Certification Date: 03/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10210 W HAPPY VALLEY PKWY STE 150
PEORIA AZ
85383-2881
US

IV. Provider business mailing address

7926 W EMORY LN
PEORIA AZ
85383-1024
US

V. Phone/Fax

Practice location:
  • Phone: 623-230-2297
  • Fax:
Mailing address:
  • Phone: 720-470-1091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: NINO POLLACCIA
Title or Position: OWNER
Credential: DDS
Phone: 623-230-2297