MEDICARE: ANTHEM CENTER FOR ORAL FACIAL SURGERY PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	D6337	AZ

General Provider Information

NPI Number	:	1396000394
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANTHEM CENTER FOR ORAL FACIAL SURGERY PC

Provider Business Mailing Address
First Line	:	42104 N VENTURE DR STE A106
Second Line	:
City	:	ANTHEM
State	:	AZ
Zip	:	85086-3824
Country	:	US
Telephone Number	:	623-551-6556
Fax Number	:	623-551-6557

Provider Business Practice Location Address
First Line	:	42104 N VENTURE DR STE A106
Second Line	:
City	:	ANTHEM
State	:	AZ
Zip	:	85086-3824
Country	:	US
Telephone Number	:	623-551-6556
Fax Number	:	623-551-6557

Authorized Official
Title or Position	:	OWNER
Name	:	DR. BRIAN J DORFMAN
Credential	:	DMD, MD
Telephone Number	:	623-551-6556

Provider Enumeration Date	:	07/06/2012
Last Update Date	:	07/06/2012

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Directions to “ANTHEM CENTER FOR ORAL FACIAL SURGERY PC ” Practice Location

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