Healthcare Provider Details

I. General information

NPI: 1063893295
Provider Name (Legal Business Name): PINNACLE PEAK ORAL SURGERY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2015
Last Update Date: 06/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8575 E PRINCESS DR SUITE #217
SCOTTSDALE AZ
85255-5483
US

IV. Provider business mailing address

3626 WYANDOT ST
DENVER CO
80211-2951
US

V. Phone/Fax

Practice location:
  • Phone: 480-342-8200
  • Fax:
Mailing address:
  • Phone: 303-513-7371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License NumberD9251
License Number StateAZ

VIII. Authorized Official

Name: EUGENE JUNG KIM
Title or Position: OWNER
Credential: DDS
Phone: 303-513-7371