Provider Demographics
NPI:1336101070
Name:CENTURY ORAL SURGERY PC
Entity Type:Organization
Organization Name:CENTURY ORAL SURGERY PC
Other - Org Name:RUSSELL T WIBLE DMD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:WIBLE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:724-981-4222
Mailing Address - Street 1:684 NORTH HERMITAGE RD
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:PA
Mailing Address - Zip Code:16148
Mailing Address - Country:US
Mailing Address - Phone:724-981-4222
Mailing Address - Fax:724-981-4228
Practice Address - Street 1:684 NORTH HERMITAGE RD
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:PA
Practice Address - Zip Code:16148
Practice Address - Country:US
Practice Address - Phone:724-981-4222
Practice Address - Fax:724-981-4228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-06
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS027889L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000325486OtherONE NATION
2375673OtherAETNA HMO
PA204563OtherUPMC
4420848OtherAETNA PPO
PA419683OtherBC BS
PA204563OtherUPMC
PA419683OtherBC BS