Provider Demographics
NPI:1104002294
Name:ORAL SURGERY OFFICE INC
Entity Type:Organization
Organization Name:ORAL SURGERY OFFICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:REGINALD
Authorized Official - Middle Name:E
Authorized Official - Last Name:GOWANS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:916-782-2161
Mailing Address - Street 1:730 SUNRISE AVE
Mailing Address - Street 2:STE 130
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661
Mailing Address - Country:US
Mailing Address - Phone:916-782-2161
Mailing Address - Fax:916-782-0677
Practice Address - Street 1:730 SUNRISE AVE
Practice Address - Street 2:STE 130
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661
Practice Address - Country:US
Practice Address - Phone:916-782-2161
Practice Address - Fax:916-782-0677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-18
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1043408925OtherDR GOWANS