Provider Demographics
NPI:1346310505
Name:ASSOCIATED ORAL & MAXILLOFACIAL SURGEONS, PC
Entity Type:Organization
Organization Name:ASSOCIATED ORAL & MAXILLOFACIAL SURGEONS, PC
Other - Org Name:DRS. RUSSELL, PIKE & NELSON, PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-263-0991
Mailing Address - Street 1:1007 SUSHRUTA DRIVE
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401
Mailing Address - Country:US
Mailing Address - Phone:304-263-0991
Mailing Address - Fax:304-274-9546
Practice Address - Street 1:1007 SUSHRUTA DRIVE
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401
Practice Address - Country:US
Practice Address - Phone:304-263-0991
Practice Address - Fax:304-274-9546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810006011Medicaid
WV3810006011Medicaid