Provider Demographics
NPI:1831292226
Name:ORAL & MAXILLOFACIAL SURGERY PSC INC
Entity Type:Organization
Organization Name:ORAL & MAXILLOFACIAL SURGERY PSC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WINFIELD
Authorized Official - Middle Name:C
Authorized Official - Last Name:JOHN
Authorized Official - Suffix:III
Authorized Official - Credentials:DMD
Authorized Official - Phone:606-329-2219
Mailing Address - Street 1:2301 LEXINGTON AVE
Mailing Address - Street 2:STE 120
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101
Mailing Address - Country:US
Mailing Address - Phone:606-329-2219
Mailing Address - Fax:606-325-9997
Practice Address - Street 1:2301 LEXINGTON AVE
Practice Address - Street 2:STE 120
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101
Practice Address - Country:US
Practice Address - Phone:606-329-2219
Practice Address - Fax:606-325-9997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4340261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60043403Medicaid
1332701Medicare ID - Type Unspecified
KY60043403Medicaid