1588759609 NPI number — BLUE ASH ORAL AND MAXILLOFACIAL SURGERY, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588759609 NPI number — BLUE ASH ORAL AND MAXILLOFACIAL SURGERY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUE ASH ORAL AND MAXILLOFACIAL SURGERY, INC
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:
Provider Other Organization Name Type Code:
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:
1588759609
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/04/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4350 MALSBARY RD
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45242-5621
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-984-2100
Provider Business Mailing Address Fax Number:
513-984-2155

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4350 MALSBARY RD
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
CINCINNATI
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45242-5621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-984-2100
Provider Business Practice Location Address Fax Number:
513-984-2155
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
STASTNY
Authorized Official First Name:
RANDALL
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
513-984-2100

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  30-1-8892 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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