1336101070 NPI number — CENTURY ORAL SURGERY PC

Table of content: (NPI 1336101070)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336101070 NPI number — CENTURY ORAL SURGERY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTURY ORAL SURGERY 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:
Provider Other Organization Name Type Code:
6
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:
1336101070
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/25/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
684 NORTH HERMITAGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HERMITAGE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16148
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-981-4222
Provider Business Mailing Address Fax Number:
724-981-4228

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
684 NORTH HERMITAGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HERMITAGE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16148
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-981-4222
Provider Business Practice Location Address Fax Number:
724-981-4228
Provider Enumeration Date:
04/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WIBLE
Authorized Official First Name:
RUSSELL
Authorized Official Middle Name:
THOMAS
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
724-981-4222

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  DS027889L , 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: 000000325486 . This is a "ONE NATION" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2375673 . This is a "AETNA HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 204563 . This is a "UPMC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 4420848 . This is a "AETNA PPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 419683 . This is a "BC BS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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