Provider Demographics
NPI:1063468163
Name:MAINE ORAL & MAXILLOFACIAL SURGERY ASSOCIATES, P.A.
Entity Type:Organization
Organization Name:MAINE ORAL & MAXILLOFACIAL SURGERY ASSOCIATES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:V
Authorized Official - Last Name:GALLUP
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:207-514-7171
Mailing Address - Street 1:211 MOUNT AUBURN AVENUE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:ME
Mailing Address - Zip Code:04210-8521
Mailing Address - Country:US
Mailing Address - Phone:207-514-7171
Mailing Address - Fax:207-514-7177
Practice Address - Street 1:211 MOUNT AUBURN AVE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-8521
Practice Address - Country:US
Practice Address - Phone:207-514-7171
Practice Address - Fax:207-514-7177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEME0562Medicare ID - Type UnspecifiedGROUP ID #