Healthcare Provider Details

I. General information

NPI: 1255421897
Provider Name (Legal Business Name): ORAL SURGERY LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1277 E MISSOURI AVE #110
PHOENIX AZ
85014-2915
US

IV. Provider business mailing address

1277 E MISSOURI AVE #110
PHOENIX AZ
85014-2915
US

V. Phone/Fax

Practice location:
  • Phone: 602-248-8745
  • Fax: 602-248-7939
Mailing address:
  • Phone: 602-248-8745
  • Fax: 602-248-7939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number1421
License Number StateAZ

VIII. Authorized Official

Name: LEE ROBERT RADDATZ
Title or Position: PRESIDENT
Credential: DDS
Phone: 602-248-8745