Provider Demographics
NPI:1497808588
Name:ORAL AND MAXILLOFACIAL SURGERY ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:ORAL AND MAXILLOFACIAL SURGERY ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:BONAMI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-789-8070
Mailing Address - Street 1:105 E 1ST ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-4249
Mailing Address - Country:US
Mailing Address - Phone:630-789-8070
Mailing Address - Fax:630-850-7537
Practice Address - Street 1:105 E 1ST ST
Practice Address - Street 2:SUITE 103
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-4249
Practice Address - Country:US
Practice Address - Phone:630-789-8070
Practice Address - Fax:630-850-7537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL207739Medicare ID - Type UnspecifiedGROUP#,OLYMPIA FIELDS LOC
IL207736Medicare ID - Type UnspecifiedGROUP #,HINSDALE LOCATION
IL207738Medicare ID - Type UnspecifiedGROUP #,AURORA LOCATION
IL207684Medicare ID - Type UnspecifiedGROUP #,CHICAGO LOCATION