=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487651071
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ORAL AND MAXILLOFACIAL SURGEONS OF NORTHERN ARIZONA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2005
-----------------------------------------------------
Last Update Date | 10/16/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 77 W FOREST AVE STE 107
-----------------------------------------------------
City | FLAGSTAFF
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86001-1482
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-773-2530
-----------------------------------------------------
Fax | 928-773-2532
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 77 W FOREST AVE STE 107
-----------------------------------------------------
City | FLAGSTAFF
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86001-1482
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-773-2530
-----------------------------------------------------
Fax | 928-773-2532
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | LORIN DEAN PETERSON
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 928-773-2530
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0106X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Pathology Dentistry
-----------------------------------------------------
License Number | 2803
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------