Provider Demographics
NPI:1972896785
Name:SONORA ORAL & MAXILLOFACIAL SURGERY DENTAL GROUP
Entity Type:Organization
Organization Name:SONORA ORAL & MAXILLOFACIAL SURGERY DENTAL GROUP
Other - Org Name:SONORA ORAL & MAXILLOFACIAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SLIM
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUCHOUCHA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:209-532-5578
Mailing Address - Street 1:940 SYLVA LN
Mailing Address - Street 2:SUITE K-1
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-5969
Mailing Address - Country:US
Mailing Address - Phone:209-532-5578
Mailing Address - Fax:209-532-6730
Practice Address - Street 1:940 SYLVA LN
Practice Address - Street 2:SUITE K-1
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-5969
Practice Address - Country:US
Practice Address - Phone:209-532-5578
Practice Address - Fax:209-532-6730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-26
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty