Healthcare Provider Details

I. General information

NPI: 1891905006
Provider Name (Legal Business Name): ARIZONA CRANIOFACIAL & PLASTIC SURGERY CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 06/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15721 N GREENWAY HAYDEN LOOP #201
SCOTTSDALE AZ
85260-1650
US

IV. Provider business mailing address

15721 N GREENWAY HAYDEN LOOP #201
SCOTTSDALE AZ
85260-1650
US

V. Phone/Fax

Practice location:
  • Phone: 480-905-9211
  • Fax: 480-905-0504
Mailing address:
  • Phone: 480-905-9211
  • Fax: 480-905-0504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number23958
License Number StateAZ

VIII. Authorized Official

Name: AMBER ALENE WALLIS
Title or Position: OFFICE MANAGER
Credential:
Phone: 480-905-9211