Healthcare Provider Details

I. General information

NPI: 1275925265
Provider Name (Legal Business Name): ORAL AND FACIAL SURGERY CENTER OF PRESCOTT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2015
Last Update Date: 07/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5415 DISTICTION WAY
PRESCOTT AZ
86301
US

IV. Provider business mailing address

5415 DISTICTION WAY
PRESCOTT AZ
86301
US

V. Phone/Fax

Practice location:
  • Phone: 205-470-0047
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number8911
License Number StateAZ

VIII. Authorized Official

Name: BENJAMIN ABT
Title or Position: OWNER/PROVIDER
Credential: DMD
Phone: 205-470-0047