Healthcare Provider Details

I. General information

NPI: 1861032005
Provider Name (Legal Business Name): SCOTTSDALE FACIAL & ORAL SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2020
Last Update Date: 01/15/2020
Certification Date: 01/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 N SCOTTSDALE RD STE 226
SCOTTSDALE AZ
85251-5630
US

IV. Provider business mailing address

3501 N SCOTTSDALE RD STE 226
SCOTTSDALE AZ
85251-5630
US

V. Phone/Fax

Practice location:
  • Phone: 480-941-5005
  • Fax: 480-946-0268
Mailing address:
  • Phone: 480-941-5005
  • Fax: 480-946-0268

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: MS. KELLI JIMENEZ
Title or Position: FINANCIAL COORDINATOR
Credential:
Phone: 480-941-5005