Provider Demographics
NPI:1710133004
Name:NORTH VALLEY CENTER FOR ORAL AND IMPLANT SURGERY, P.C.
Entity Type:Organization
Organization Name:NORTH VALLEY CENTER FOR ORAL AND IMPLANT SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL AND MAXILLOFACIAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:602-978-2890
Mailing Address - Street 1:4025 W BELL RD
Mailing Address - Street 2:SUITE 9
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85053-2750
Mailing Address - Country:US
Mailing Address - Phone:602-978-2890
Mailing Address - Fax:602-978-5794
Practice Address - Street 1:4025 W BELL RD
Practice Address - Street 2:SUITE 9
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85053-2750
Practice Address - Country:US
Practice Address - Phone:602-978-2890
Practice Address - Fax:602-978-5794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-18
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ55831223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ70901Medicare PIN