1629546171 NPI number — SAN TAN VALLEY ORAL FACIAL AND IMPLANT SURGERY PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629546171 NPI number — SAN TAN VALLEY ORAL FACIAL AND IMPLANT SURGERY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAN TAN VALLEY ORAL FACIAL AND IMPLANT SURGERY PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629546171
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/02/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2450 W RAY RD STE 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHANDLER
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85224-3595
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-814-9500
Provider Business Mailing Address Fax Number:
480-814-9501

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
36327 N GANTZEL RD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
SAN TAN VALLEY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-814-9500
Provider Business Practice Location Address Fax Number:
520-210-0442
Provider Enumeration Date:
11/02/2018

Additional Information

Authorized Official

Authorized Official Last Name:
SHAH
Authorized Official First Name:
NISHITH
Authorized Official Middle Name:
S
Authorized Official Title or Position:
DOCTOR/OWNER
Authorized Official Telephone Number:
480-814-9500

Provider Taxonomy Codes

  • Taxonomy code: 204E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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