Healthcare Provider Details

I. General information

NPI: 1942703657
Provider Name (Legal Business Name): ADVANCED IMPLANT AND ORAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2018
Last Update Date: 04/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 W 16TH ST STE 3
YUMA AZ
85364-4496
US

IV. Provider business mailing address

1325 W 16TH ST STE 3
YUMA AZ
85364-4496
US

V. Phone/Fax

Practice location:
  • Phone: 928-329-6447
  • Fax: 928-782-8036
Mailing address:
  • Phone: 928-329-6447
  • Fax: 928-782-8036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. PETER A SPANGANBERG
Title or Position: OWNER
Credential: DDS
Phone: 480-279-3113