Healthcare Provider Details

I. General information

NPI: 1801483318
Provider Name (Legal Business Name): FACIAL AND ORAL SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2020
Last Update Date: 12/30/2020
Certification Date: 12/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1893 NE NEFF RD
BEND OR
97701-6112
US

IV. Provider business mailing address

1893 NE NEFF RD
BEND OR
97701-6112
US

V. Phone/Fax

Practice location:
  • Phone: 541-382-7981
  • Fax:
Mailing address:
  • Phone: 541-382-7981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: AMIR AZARISAMANI
Title or Position: PRESIDENT
Credential: MD, DMD
Phone: 904-993-3599