=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871013524
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANTHEM ORAL SURGERY & IMPLANT CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2017
-----------------------------------------------------
Last Update Date | 06/27/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 42104 N VENTURE DR
-----------------------------------------------------
City | ANTHEM
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85086-3823
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-575-0844
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30012 N CAVE CREEK RD STE 103
-----------------------------------------------------
City | CAVE CREEK
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85331-5833
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-575-0844
-----------------------------------------------------
Fax | 480-575-0845
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SURGEON
-----------------------------------------------------
Name | DR. BROWN HARRIS III
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 480-575-0844
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | D5779
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------