Provider Demographics
NPI:1073664074
Name:NORTHEAST ORAL & MAXILLOFACIAL SURGEONS, INC
Entity Type:Organization
Organization Name:NORTHEAST ORAL & MAXILLOFACIAL SURGEONS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:P
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:216-261-1010
Mailing Address - Street 1:26300 EUCLID AVE
Mailing Address - Street 2:SUITE 410
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44132-3708
Mailing Address - Country:US
Mailing Address - Phone:216-261-1010
Mailing Address - Fax:216-261-9442
Practice Address - Street 1:26300 EUCLID AVE
Practice Address - Street 2:SUITE 410
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44132-3708
Practice Address - Country:US
Practice Address - Phone:216-261-1010
Practice Address - Fax:216-261-9442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0151771223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHT47184Medicare UPIN
OH0563252Medicare ID - Type Unspecified