Provider Demographics
NPI:1700817384
Name:UNIVERSITY ORAL & MAXILLOFACIAL SURGERY LTD
Entity Type:Organization
Organization Name:UNIVERSITY ORAL & MAXILLOFACIAL SURGERY LTD
Other - Org Name:ORAL SURGERY ASSOICATES LTD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FRANCIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:CONNOR
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:401-885-8575
Mailing Address - Street 1:1370 S COUNTY TRL
Mailing Address - Street 2:
Mailing Address - City:EAST GREENWICH
Mailing Address - State:RI
Mailing Address - Zip Code:02818-1625
Mailing Address - Country:US
Mailing Address - Phone:401-885-8575
Mailing Address - Fax:401-885-8577
Practice Address - Street 1:1370 S COUNTY TRL
Practice Address - Street 2:
Practice Address - City:EAST GREENWICH
Practice Address - State:RI
Practice Address - Zip Code:02818-1625
Practice Address - Country:US
Practice Address - Phone:401-885-8575
Practice Address - Fax:401-885-8577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI14711223S0112X
RI16551223S0112X
RI24111223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIUO19657Medicaid
MARG0143OtherBLUE CROSS PAWTUCKET
MAX11456OtherBLUE CROSS-COVENTRY
MARG0144OtherBLUE CROSS-EG
MARG0144OtherBLUE CROSS-EG