Provider Demographics
NPI:1558452177
Name:ORAL & MAXILLOFACIAL SURGERY ASSOCIATES, P.A.
Entity Type:Organization
Organization Name:ORAL & MAXILLOFACIAL SURGERY ASSOCIATES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:L
Authorized Official - Last Name:GOODWILL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:302-655-6183
Mailing Address - Street 1:1304 N BROOM ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19806-4254
Mailing Address - Country:US
Mailing Address - Phone:302-655-6183
Mailing Address - Fax:302-655-8635
Practice Address - Street 1:1304 N BROOM ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19806-4254
Practice Address - Country:US
Practice Address - Phone:302-655-6183
Practice Address - Fax:302-655-8635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEGI-00008441223S0112X
DEGI-00009301223S0112X
DEGI-00011071223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE158366Medicare PIN