Provider Demographics
NPI:1063529394
Name:ARIZONA CENTER FOR IMPLANTS, FACIAL, AND ORAL SURGERY
Entity type:Organization
Organization Name:ARIZONA CENTER FOR IMPLANTS, FACIAL, AND ORAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:K
Authorized Official - Last Name:LINES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:623-931-9197
Mailing Address - Street 1:18301 N 79TH AVE
Mailing Address - Street 2:SUITE G-185
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-8463
Mailing Address - Country:US
Mailing Address - Phone:623-931-9197
Mailing Address - Fax:623-937-4385
Practice Address - Street 1:18301 N 79TH AVE
Practice Address - Street 2:SUITE G-185
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8463
Practice Address - Country:US
Practice Address - Phone:623-931-9197
Practice Address - Fax:623-937-4385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ=========OtherEIN