Provider Demographics
NPI:1508166562
Name:CENTER FOR ORAL AND MAXILLOFACIAL RECONSTRUCTIVE SURGERY
Entity Type:Organization
Organization Name:CENTER FOR ORAL AND MAXILLOFACIAL RECONSTRUCTIVE SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALI
Authorized Official - Middle Name:
Authorized Official - Last Name:PASHAPOUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-223-2678
Mailing Address - Street 1:3700 MASSACHUSETTS AVE NW
Mailing Address - Street 2:SUITE 116
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20016-5800
Mailing Address - Country:US
Mailing Address - Phone:973-223-2678
Mailing Address - Fax:
Practice Address - Street 1:3001 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:CHEVERLY
Practice Address - State:MD
Practice Address - Zip Code:20785-1189
Practice Address - Country:US
Practice Address - Phone:973-223-2678
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-25
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD140101223S0112X
VA04014118541223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty