Healthcare Provider Details

I. General information

NPI: 1538275011
Provider Name (Legal Business Name): NORTHWEST VALLEY ORAL AND FACIAL SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 03/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16936 W BELL RD STE 203
SURPRISE AZ
85374-8949
US

IV. Provider business mailing address

16936 W BELL RD STE 203
SURPRISE AZ
85374-8949
US

V. Phone/Fax

Practice location:
  • Phone: 623-583-1875
  • Fax: 623-583-1969
Mailing address:
  • Phone: 623-583-1875
  • Fax: 623-583-1969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number6938
License Number StateAZ

VIII. Authorized Official

Name: DR. BRADLEY TAYLER HAMMOND
Title or Position: PRESIDENT
Credential: D.D.S., M.D.
Phone: 623-583-1875