Provider Demographics
NPI:1760661789
Name:WARREN ORAL AND FACIAL SURGERY, INC.
Entity Type:Organization
Organization Name:WARREN ORAL AND FACIAL SURGERY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:MCCLAIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:330-856-7950
Mailing Address - Street 1:8893 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-2351
Mailing Address - Country:US
Mailing Address - Phone:330-856-7950
Mailing Address - Fax:330-856-1447
Practice Address - Street 1:8893 E MARKET ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-2351
Practice Address - Country:US
Practice Address - Phone:330-856-7950
Practice Address - Fax:330-856-1447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-25
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35075926204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2114054Medicaid
OHG93612Medicare UPIN