Provider Demographics
NPI:1376299131
Name:DESERT SOUTHWEST ORAL AND FACIAL SURGERY
Entity Type:Organization
Organization Name:DESERT SOUTHWEST ORAL AND FACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:BIDWELL
Authorized Official - Last Name:SIKES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:970-516-4100
Mailing Address - Street 1:33 N ELM ST STE B
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-3105
Mailing Address - Country:US
Mailing Address - Phone:205-572-1035
Mailing Address - Fax:970-632-6178
Practice Address - Street 1:33 N ELM ST STE B
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-3105
Practice Address - Country:US
Practice Address - Phone:970-516-4100
Practice Address - Fax:970-632-6178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-01
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01385828Medicaid
AZ251853Medicaid
NM22603085Medicaid