Provider Demographics
NPI:1881189199
Name:DESERT VALLEY ORAL SURGERY
Entity Type:Organization
Organization Name:DESERT VALLEY ORAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DONOVAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-539-6420
Mailing Address - Street 1:2915 E. BASELINE ROAD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234
Mailing Address - Country:US
Mailing Address - Phone:480-539-6420
Mailing Address - Fax:480-663-6370
Practice Address - Street 1:2915 E. BASELINE ROAD
Practice Address - Street 2:SUITE 106
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234
Practice Address - Country:US
Practice Address - Phone:480-539-6420
Practice Address - Fax:480-663-6370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-28
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD08601204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty