Provider Demographics
NPI:1629546171
Name:SAN TAN VALLEY ORAL FACIAL AND IMPLANT SURGERY PLLC
Entity Type:Organization
Organization Name:SAN TAN VALLEY ORAL FACIAL AND IMPLANT SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NISHITH
Authorized Official - Middle Name:S
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:480-814-9500
Mailing Address - Street 1:2450 W RAY RD STE 1
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-3595
Mailing Address - Country:US
Mailing Address - Phone:480-814-9500
Mailing Address - Fax:480-814-9501
Practice Address - Street 1:36327 N GANTZEL RD
Practice Address - Street 2:SUITE 102
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85140
Practice Address - Country:US
Practice Address - Phone:480-814-9500
Practice Address - Fax:520-210-0442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-02
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty