Provider Demographics
NPI:1629176623
Name:CENTRAL MASS ORAL AND MAXILLOFACIAL SURGERY, P.C.
Entity Type:Organization
Organization Name:CENTRAL MASS ORAL AND MAXILLOFACIAL SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARMINE
Authorized Official - Middle Name:A
Authorized Official - Last Name:COLARUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:978-534-8300
Mailing Address - Street 1:2 JUNGLE RD
Mailing Address - Street 2:
Mailing Address - City:LEOMINSTER
Mailing Address - State:MA
Mailing Address - Zip Code:01453-5208
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 JUNGLE RD
Practice Address - Street 2:
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453
Practice Address - Country:US
Practice Address - Phone:978-534-8300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM11760Medicare ID - Type UnspecifiedMEDICARE GROUP #