Provider Demographics
NPI:1114355575
Name:PHOENIX MAXILLOFACIAL TRAUMA ASSOCIATES, LLC
Entity Type:Organization
Organization Name:PHOENIX MAXILLOFACIAL TRAUMA ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLAS
Authorized Official - Middle Name:PHILIPPE
Authorized Official - Last Name:BEBEAU
Authorized Official - Suffix:
Authorized Official - Credentials:MD, DDS
Authorized Official - Phone:480-300-7152
Mailing Address - Street 1:5410 N SCOTTSDALE RD
Mailing Address - Street 2:SUITE B-110
Mailing Address - City:PARADISE VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85253-5927
Mailing Address - Country:US
Mailing Address - Phone:480-300-7152
Mailing Address - Fax:480-725-0228
Practice Address - Street 1:5410 N SCOTTSDALE RD
Practice Address - Street 2:SUITE B-110
Practice Address - City:PARADISE VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85253-5927
Practice Address - Country:US
Practice Address - Phone:480-300-7152
Practice Address - Fax:480-725-0228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-23
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ47593204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty