Provider Demographics
NPI:1164156725
Name:NORTHERN ARIZONA ORAL SURGERY PC
Entity Type:Organization
Organization Name:NORTHERN ARIZONA ORAL SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR. OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WHITNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PAVICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-857-7947
Mailing Address - Street 1:1521 N BEAVER ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-1484
Mailing Address - Country:US
Mailing Address - Phone:928-773-2530
Mailing Address - Fax:928-773-2532
Practice Address - Street 1:1521 N BEAVER ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1484
Practice Address - Country:US
Practice Address - Phone:928-773-2530
Practice Address - Fax:928-773-2532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-11
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery