Provider Demographics
NPI:1073641148
Name:DELAWARE VALLEY MAXILLOFACIAL & ORAL SURGERY LLC
Entity Type:Organization
Organization Name:DELAWARE VALLEY MAXILLOFACIAL & ORAL SURGERY LLC
Other - Org Name:SOUTHEASTERN PA ORAL SURGERY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:215-707-7138
Mailing Address - Street 1:100 E LEHIGH AVE
Mailing Address - Street 2:PM2
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19125-1012
Mailing Address - Country:US
Mailing Address - Phone:215-707-7138
Mailing Address - Fax:215-707-5405
Practice Address - Street 1:2301 E ALLEGHENY AVE STE 206
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134-4427
Practice Address - Country:US
Practice Address - Phone:267-367-5009
Practice Address - Fax:267-367-5476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA088589Medicare PIN