Provider Demographics
NPI:1407398787
Name:SOUTHWEST CENTER FOR ORAL SURGERY, PLLC
Entity type:Organization
Organization Name:SOUTHWEST CENTER FOR ORAL SURGERY, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:FAWNE
Authorized Official - Middle Name:E
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-792-5794
Mailing Address - Street 1:6677 W THUNDERBIRD RD
Mailing Address - Street 2:SUITE H120
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-3709
Mailing Address - Country:US
Mailing Address - Phone:623-792-5794
Mailing Address - Fax:623-792-5809
Practice Address - Street 1:6677 W THUNDERBIRD RD
Practice Address - Street 2:SUITE H120
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-3709
Practice Address - Country:US
Practice Address - Phone:623-792-5794
Practice Address - Fax:623-792-5809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-17
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD80771223S0112X
AZD91331223S0112X
AZD31781223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty