Provider Demographics
NPI:1922437920
Name:ORAL & MAXILLOFACIAL SURGERY OF PHOENIX
Entity Type:Organization
Organization Name:ORAL & MAXILLOFACIAL SURGERY OF PHOENIX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BEBEAU
Authorized Official - Suffix:
Authorized Official - Credentials:MD, DDS
Authorized Official - Phone:480-745-2430
Mailing Address - Street 1:5410 N SCOTTSDALE RD STE B100
Mailing Address - Street 2:
Mailing Address - City:PARADISE VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85253-5907
Mailing Address - Country:US
Mailing Address - Phone:480-745-2430
Mailing Address - Fax:
Practice Address - Street 1:5410 N SCOTTSDALE RD STE B100
Practice Address - Street 2:
Practice Address - City:PARADISE VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85253-5907
Practice Address - Country:US
Practice Address - Phone:480-745-2430
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-11
Last Update Date:2013-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ84031223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty