Provider Demographics
NPI:1407070006
Name:FACIAL AND ORAL SURGERY ASSOCIATES
Entity Type:Organization
Organization Name:FACIAL AND ORAL SURGERY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT / SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:R.
Authorized Official - Middle Name:RUBERT
Authorized Official - Last Name:BERUBE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-622-5814
Mailing Address - Street 1:5 COMMUNITY DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-8087
Mailing Address - Country:US
Mailing Address - Phone:207-622-5814
Mailing Address - Fax:207-621-4360
Practice Address - Street 1:5 COMMUNITY DR
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-8087
Practice Address - Country:US
Practice Address - Phone:207-622-5814
Practice Address - Fax:207-621-4360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME34231223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEM53500OtherCIGNA HEALTHCARE
ME2091238OtherAETNA NUMBER
ME826700OtherUNITED CONCORDIA
MEK0832OtherANTHEM BLUE CROSS
MEK0832OtherANTHEM BLUE CROSS
MEM53500OtherCIGNA HEALTHCARE
ME2091238OtherAETNA NUMBER