Provider Demographics
NPI:1497265516
Name:PEORIA ORAL & IMPLANT SURGERY PLLC
Entity Type:Organization
Organization Name:PEORIA ORAL & IMPLANT SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NINO
Authorized Official - Middle Name:
Authorized Official - Last Name:POLLACCIA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:623-230-2297
Mailing Address - Street 1:7926 W EMORY LN
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-1024
Mailing Address - Country:US
Mailing Address - Phone:720-470-1091
Mailing Address - Fax:
Practice Address - Street 1:10210 W HAPPY VALLEY PKWY STE 150
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-2881
Practice Address - Country:US
Practice Address - Phone:623-230-2297
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-03
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
No261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial SurgeryGroup - Single Specialty