Provider Demographics
NPI:1124222971
Name:POCONO CENTER FOR ORAL, FACIAL & IMPLANT SURGERY
Entity Type:Organization
Organization Name:POCONO CENTER FOR ORAL, FACIAL & IMPLANT SURGERY
Other - Org Name:POCONO ORAL MAXILLOFACIAL SURGERY CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:ALBERTO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:570-491-4145
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:16 PENNSYLVANIA AVE
Mailing Address - City:MATAMORAS
Mailing Address - State:PA
Mailing Address - Zip Code:18336
Mailing Address - Country:US
Mailing Address - Phone:570-491-4145
Mailing Address - Fax:570-491-5119
Practice Address - Street 1:16 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:MATAMORAS
Practice Address - State:PA
Practice Address - Zip Code:18336
Practice Address - Country:US
Practice Address - Phone:570-491-4145
Practice Address - Fax:570-491-5119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-14
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0352871223G0001X
PADS020813L1223P0106X
PADS030426L1223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAT28289Medicare UPIN
PAU74511Medicare UPIN
PA057374Medicare ID - Type UnspecifiedMEDICARE
PASTO82152Medicare ID - Type UnspecifiedPROVIDER NUMBER