Provider Demographics
NPI:1790860153
Name:NORTHEAST ORAL AND MAXILLOFACIAL SURGERY
Entity Type:Organization
Organization Name:NORTHEAST ORAL AND MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:FRASER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:614-471-6600
Mailing Address - Street 1:463 WATERBURY COURT
Mailing Address - Street 2:SUITE A
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230
Mailing Address - Country:US
Mailing Address - Phone:614-471-6600
Mailing Address - Fax:614-471-6660
Practice Address - Street 1:463 WATERBURY COURT
Practice Address - Street 2:SUITE A
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230
Practice Address - Country:US
Practice Address - Phone:614-471-6600
Practice Address - Fax:614-471-6660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty