Provider Demographics
NPI:1013023928
Name:AFFILIATED ORAL & MAXILLOFACIAL SURGEONS PC
Entity Type:Organization
Organization Name:AFFILIATED ORAL & MAXILLOFACIAL SURGEONS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:G
Authorized Official - Last Name:BODE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:602-938-0880
Mailing Address - Street 1:5750 W THUNDERBIRD
Mailing Address - Street 2:H-850
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306
Mailing Address - Country:US
Mailing Address - Phone:602-938-0880
Mailing Address - Fax:602-547-0528
Practice Address - Street 1:5750 W THUNDERBIRD
Practice Address - Street 2:H-850
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306
Practice Address - Country:US
Practice Address - Phone:602-938-0880
Practice Address - Fax:602-547-0528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25791223S0112X
AZ59501223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty