=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255759650
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IMPLANT&MAXILLOFACIAL SURGICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2014
-----------------------------------------------------
Last Update Date | 04/02/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2224 1ST AVE W STE 2
-----------------------------------------------------
City | WILLISTON
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58801-6286
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-721-5254
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2224 1ST AVE W STE 2
-----------------------------------------------------
City | WILLISTON
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58801-6286
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-721-5254
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ORAL&MAXILLOFACIAL SURGEON/OWNER
-----------------------------------------------------
Name | DR. JUAN J. ULLOA
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 701-721-5254
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 1993
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------