Provider Demographics
NPI:1568667061
Name:ORAL & FACIAL SURGEONS OF ARIZONA
Entity Type:Organization
Organization Name:ORAL & FACIAL SURGEONS OF ARIZONA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:SABOL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:602-957-0332
Mailing Address - Street 1:5050 N. 40TH STREET
Mailing Address - Street 2:SUITE 180
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018
Mailing Address - Country:US
Mailing Address - Phone:602-957-0332
Mailing Address - Fax:602-957-3282
Practice Address - Street 1:5050 N. 40TH STREET
Practice Address - Street 2:SUITE 180
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018
Practice Address - Country:US
Practice Address - Phone:602-957-0332
Practice Address - Fax:602-957-3282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-15
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ61471223S0112X
AZ68161223S0112X
AZ1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ083717Medicaid
AZ931920Medicaid
AZ089805Medicaid