Provider Demographics
NPI:1619693793
Name:PHOENIX ORAL SURGERY ASSOCIATES PLLC
Entity Type:Organization
Organization Name:PHOENIX ORAL SURGERY ASSOCIATES PLLC
Other - Org Name:DESERT RIDGE ORAL SURGERY INSTITUTE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VISHTASB
Authorized Official - Middle Name:N/A
Authorized Official - Last Name:BROUMAND
Authorized Official - Suffix:
Authorized Official - Credentials:DMD MD
Authorized Official - Phone:480-284-8087
Mailing Address - Street 1:20950 N TATUM BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-4269
Mailing Address - Country:US
Mailing Address - Phone:480-284-8087
Mailing Address - Fax:
Practice Address - Street 1:20950 N TATUM BLVD STE 200
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-4269
Practice Address - Country:US
Practice Address - Phone:480-284-8087
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-19
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center