Provider Demographics
NPI:1689886657
Name:PALM VALLEY ORAL SURGERY
Entity Type:Organization
Organization Name:PALM VALLEY ORAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:J
Authorized Official - Last Name:BLAZIC
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MD
Authorized Official - Phone:623-935-5774
Mailing Address - Street 1:1646 N LITCHFIELD ROAD
Mailing Address - Street 2:STE 130
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338
Mailing Address - Country:US
Mailing Address - Phone:623-935-5774
Mailing Address - Fax:623-935-6524
Practice Address - Street 1:1646 N LITCHFIELD ROAD
Practice Address - Street 2:STE 130
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338
Practice Address - Country:US
Practice Address - Phone:623-935-5774
Practice Address - Fax:623-935-6524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZM31657204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1497843445Medicare UPIN