Provider Demographics
NPI:1336689140
Name:SOUTHWEST CENTER FOR ORAL SURGERY, PLLC
Entity Type:Organization
Organization Name:SOUTHWEST CENTER FOR ORAL SURGERY, PLLC
Other - Org Name:SOUTHWEST ORAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:FAWNE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-792-5794
Mailing Address - Street 1:6677 W THUNDERBIRD RD STE H120
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-3726
Mailing Address - Country:US
Mailing Address - Phone:623-792-5794
Mailing Address - Fax:623-792-5809
Practice Address - Street 1:4600 E SHEA BLVD
Practice Address - Street 2:#201
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-6024
Practice Address - Country:US
Practice Address - Phone:623-792-5794
Practice Address - Fax:623-792-5809
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHWEST CENTER FOR ORAL SURGERY, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-27
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD80771223S0112X
AZD91331223S0112X
AZD31781223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty