1255585873 NPI number — ABSOLUTE ORAL SURGERY & IMPLANT CENTERS PC

Table of content: (NPI 1255585873)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255585873 NPI number — ABSOLUTE ORAL SURGERY & IMPLANT CENTERS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ABSOLUTE ORAL SURGERY & IMPLANT CENTERS PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ABSOLUTE ORAL SURGERY & IMPLANT CENTERS PC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255585873
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
456 SCHOOL LN
Provider Second Line Business Mailing Address:
103
Provider Business Mailing Address City Name:
HARLEYSVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19438-1715
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-513-7172
Provider Business Mailing Address Fax Number:
215-513-7192

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
456 SCHOOL LN
Provider Second Line Business Practice Location Address:
103
Provider Business Practice Location Address City Name:
HARLEYSVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19438-1715
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-513-7172
Provider Business Practice Location Address Fax Number:
215-513-7192
Provider Enumeration Date:
11/10/2008

Additional Information

Authorized Official

Authorized Official Last Name:
GRETZULA
Authorized Official First Name:
CHAD
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
215-513-7172

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  DS 035849 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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