Provider Demographics
NPI:1760755730
Name:SOUTHWEST CENTER FOR ORAL, FACIAL AND DENTAL IMPLANT SURGERY
Entity Type:Organization
Organization Name:SOUTHWEST CENTER FOR ORAL, FACIAL AND DENTAL IMPLANT SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JEFFERSON
Authorized Official - Last Name:BUCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD, DDS
Authorized Official - Phone:623-792-5794
Mailing Address - Street 1:6677 W THUNDERBIRD RD
Mailing Address - Street 2:SUITE H120
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-3709
Mailing Address - Country:US
Mailing Address - Phone:623-792-5794
Mailing Address - Fax:623-792-5809
Practice Address - Street 1:6677 W THUNDERBIRD RD
Practice Address - Street 2:SUITE H120
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-3709
Practice Address - Country:US
Practice Address - Phone:623-792-5794
Practice Address - Fax:623-792-5809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-21
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD80771223S0112X
AZD31781223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty