Provider Demographics
NPI:1104359959
Name:APPALACHIAN ORAL SURGERY CENTER
Entity Type:Organization
Organization Name:APPALACHIAN ORAL SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:ELWOOD
Authorized Official - Last Name:KOEPKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:304-904-7145
Mailing Address - Street 1:3433 UNIVERSITY AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-3052
Mailing Address - Country:US
Mailing Address - Phone:304-322-4532
Mailing Address - Fax:
Practice Address - Street 1:3433 UNIVERSITY AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-3052
Practice Address - Country:US
Practice Address - Phone:304-322-4532
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-09
Last Update Date:2017-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV40111223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty