Provider Demographics
NPI:1700037710
Name:GEORGE A MARANON ORAL MAXILLOFACIAL SURGERY
Entity Type:Organization
Organization Name:GEORGE A MARANON ORAL MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARANON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-344-0110
Mailing Address - Street 1:18411 CLARK ST
Mailing Address - Street 2:SUITE # 204
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-3506
Mailing Address - Country:US
Mailing Address - Phone:818-344-0110
Mailing Address - Fax:818-344-0110
Practice Address - Street 1:18411 CLARK ST
Practice Address - Street 2:SUITE # 204
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3506
Practice Address - Country:US
Practice Address - Phone:818-344-0110
Practice Address - Fax:818-344-0110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-08
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD321271223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD32127OtherMEDICARE PTAN
CAG43517Medicare UPIN