Provider Demographics
NPI:1447037304
Name:SUNRISE MOUNTAIN ORAL AND MAXILLOFACIAL SURGERY PLLC
Entity type:Organization
Organization Name:SUNRISE MOUNTAIN ORAL AND MAXILLOFACIAL SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL AND MAXILLOFACIAL SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:602-831-2115
Mailing Address - Street 1:17620 N 42ND LN
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-2928
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20165 N 67TH AVE STE A102
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-7002
Practice Address - Country:US
Practice Address - Phone:602-831-2115
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-13
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty