MEDICARE: SOUTHWEST OROFACIAL GROUP, INC.

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	332BC3200X	Customized Equipment (DME)
2	1223X2210X	Orofacial Pain Dentistry
3	122300000X	Dentist	1607	AZ
4	1223S0112X	Oral and Maxillofacial Surgery (Dentist)

General Provider Information

NPI Number	:	1487733572
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHWEST OROFACIAL GROUP, INC.

Provider Business Mailing Address
First Line	:	10214 N TATUM BLVD STE A1100
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85028-4243
Country	:	US
Telephone Number	:	602-992-1486
Fax Number	:	602-992-6604

Provider Business Practice Location Address
First Line	:	10214 N TATUM BLVD STE A1100
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85028-4243
Country	:	US
Telephone Number	:	602-992-1486
Fax Number	:	602-992-6604

Authorized Official
Title or Position	:	OWNER
Name	:	THERESE GARVEY
Credential	:
Telephone Number	:	602-992-1486

Provider Enumeration Date	:	11/02/2006
Last Update Date	:	03/04/2026

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