1306066683 NPI number — ADVANCED ORAL AND FACIAL SURGERY OF THE MAIN LINE, P.C.

Table of content: (NPI 1306066683)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306066683 NPI number — ADVANCED ORAL AND FACIAL SURGERY OF THE MAIN LINE, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED ORAL AND FACIAL SURGERY OF THE MAIN LINE, P.C.
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:
1306066683
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/17/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
223 LANCASTER AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEVON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19333-1583
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-688-6683
Provider Business Mailing Address Fax Number:
610-971-0481

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
223 LANCASTER AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEVON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19333-1583
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-688-6683
Provider Business Practice Location Address Fax Number:
610-971-0481
Provider Enumeration Date:
04/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FUNARI
Authorized Official First Name:
GODFREY
Authorized Official Middle Name:
JOEL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
610-688-6683

Provider Taxonomy Codes

  • Taxonomy code: 261QS0112X , with the licence number:  DS023425L , 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)

  • Identifier: 1720009863 . This is a "NPI" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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