Provider Demographics
NPI:1679822761
Name:SOUTHERN ARIZONA ORAL & MAXILLOFACIAL SURGERY, P.C.
Entity Type:Organization
Organization Name:SOUTHERN ARIZONA ORAL & MAXILLOFACIAL SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:C
Authorized Official - Last Name:QUINTIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-290-6800
Mailing Address - Street 1:6369 E. TANQUE VERDE RD.
Mailing Address - Street 2:SUITE 230
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85715-3834
Mailing Address - Country:US
Mailing Address - Phone:520-290-6800
Mailing Address - Fax:520-290-2270
Practice Address - Street 1:6369 E. TANQUE VERDE RD.
Practice Address - Street 2:SUITE 230
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85715-3834
Practice Address - Country:US
Practice Address - Phone:520-290-6800
Practice Address - Fax:520-290-2270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-05
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3539261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZT93523Medicare UPIN
AZDDS3539Medicare PIN