Healthcare Provider Details

I. General information

NPI: 1114125267
Provider Name (Legal Business Name): CASAS ADOBES OMS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2007
Last Update Date: 04/13/2021
Certification Date: 04/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3150 N SWAN
TUCSON AZ
85712
US

IV. Provider business mailing address

3150 N SWAN ROAD
TUCSON AZ
85712
US

V. Phone/Fax

Practice location:
  • Phone: 520-745-6531
  • Fax: 520-790-3817
Mailing address:
  • Phone: 520-745-6531
  • Fax: 520-790-3817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number2774
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: JOANIE DE MAINE
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 520-745-6531