Provider Demographics
NPI:1689915316
Name:ELKINS PARK ORAL SURGERY, INC
Entity Type:Organization
Organization Name:ELKINS PARK ORAL SURGERY, INC
Other - Org Name:ELKINS PARK DENTAL SPECIALIST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:CHERIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:215-663-1223
Mailing Address - Street 1:7900 OLD YORK RD
Mailing Address - Street 2:115 A
Mailing Address - City:ELKINS PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19027-2318
Mailing Address - Country:US
Mailing Address - Phone:215-635-0808
Mailing Address - Fax:
Practice Address - Street 1:7900 OLD YORK RD
Practice Address - Street 2:115 A
Practice Address - City:ELKINS PARK
Practice Address - State:PA
Practice Address - Zip Code:19027-2318
Practice Address - Country:US
Practice Address - Phone:215-635-0808
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-05
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0375511223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1022041470033Medicaid