Provider Demographics
NPI:1851569693
Name:CASA GRANDE ORAL AND MAXILLOFACIAL SURGERY, P.C.
Entity Type:Organization
Organization Name:CASA GRANDE ORAL AND MAXILLOFACIAL SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:CULL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:520-876-5227
Mailing Address - Street 1:1876 E SABIN DR STE 6
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-6197
Mailing Address - Country:US
Mailing Address - Phone:520-876-5227
Mailing Address - Fax:520-836-2234
Practice Address - Street 1:1876 E SABIN DR STE 6
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-6197
Practice Address - Country:US
Practice Address - Phone:520-876-5227
Practice Address - Fax:520-836-2234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-14
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7170261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental