Provider Demographics
NPI:1982873311
Name:ARIZONA ORAL FACIAL AND IMPLANT SURGERY LLC
Entity Type:Organization
Organization Name:ARIZONA ORAL FACIAL AND IMPLANT SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CECILIA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUEBUSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-814-9500
Mailing Address - Street 1:2450 W RAY RD STE 1
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-3595
Mailing Address - Country:US
Mailing Address - Phone:480-814-9500
Mailing Address - Fax:480-814-9501
Practice Address - Street 1:2450 W RAY RD STE 1
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-3595
Practice Address - Country:US
Practice Address - Phone:480-814-9500
Practice Address - Fax:480-814-9501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-29
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31035204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ786600Medicaid
AZI12350Medicare UPIN
AZZ82656Medicare PIN