1891744462 NPI number — ORAL & FACIAL SURGERY CENTER PA

Table of content: (NPI 1891744462)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891744462 NPI number — ORAL & FACIAL SURGERY CENTER PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ORAL & FACIAL SURGERY CENTER PA
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:
MAXILLOFACIAL SURGERY CENTER
Provider Other Organization Name Type Code:
4
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:
1891744462
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4185
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72702-4185
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-717-1171
Provider Business Mailing Address Fax Number:
479-927-3085

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3996 N FRONTAGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72703-5122
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-582-3002
Provider Business Practice Location Address Fax Number:
479-582-2840
Provider Enumeration Date:
05/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BOLDING
Authorized Official First Name:
SCOTTY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
479-957-4611

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 204E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 127319680 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 230273680 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 239128680 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com