Provider Demographics
NPI:1801483318
Name:FACIAL AND ORAL SURGERY CENTER LLC
Entity type:Organization
Organization Name:FACIAL AND ORAL SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:AZARISAMANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD, DMD
Authorized Official - Phone:904-993-3599
Mailing Address - Street 1:1893 NE NEFF RD
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-6112
Mailing Address - Country:US
Mailing Address - Phone:541-382-7981
Mailing Address - Fax:
Practice Address - Street 1:1893 NE NEFF RD
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6112
Practice Address - Country:US
Practice Address - Phone:541-382-7981
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-30
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty