Provider Demographics
NPI:1487651071
Name:ORAL AND MAXILLOFACIAL SURGEONS OF NORTHERN ARIZONA
Entity Type:Organization
Organization Name:ORAL AND MAXILLOFACIAL SURGEONS OF NORTHERN ARIZONA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LORIN
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:928-773-2530
Mailing Address - Street 1:77 W FOREST AVE
Mailing Address - Street 2:STE 107
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-1482
Mailing Address - Country:US
Mailing Address - Phone:928-773-2530
Mailing Address - Fax:928-773-2532
Practice Address - Street 1:77 W FOREST AVE
Practice Address - Street 2:STE 107
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1482
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:2005-06-28
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ28031223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZWMBSRMedicare PIN