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General NPI Number Information
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NPI Number | 1588960512
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Entity Type | Organization
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Legal Business Name | DESERT RIDGE IMPLANT & ORAL SURGERY PC
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Dates
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Enumeration Date | 02/09/2011
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Last Update Date | 04/04/2011
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Provider Practice Location Address
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Address Line | 20950 N TATUM BLVD STE. 120
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City | PHOENIX
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State | AZ
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Zip | 85050-4200
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Country | US
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Telephone | 480-563-3960
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Fax | 480-563-3965
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Provider Business Mailing Address
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Address Line | 20950 N TATUM BLVD STE. 120
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City | PHOENIX
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State | AZ
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Zip | 85050-4200
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Country | US
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Telephone | 480-563-3960
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Fax | 480-563-3965
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Authorized Official
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Title or Position | OWNER
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Name | DR. MATTHEW A. DEFELICE
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Credential | DDS
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Telephone | 480-563-3960
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 5196
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License Number State | AZ
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