Provider Demographics
NPI:1922480250
Name:COMMONWEALTH ORAL AND MAXILLOFACIAL SURGERY, PSC
Entity Type:Organization
Organization Name:COMMONWEALTH ORAL AND MAXILLOFACIAL SURGERY, PSC
Other - Org Name:COMMONWEALTH ORAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:ACORD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:502-423-7822
Mailing Address - Street 1:6520 GLENRIDGE PARK PL
Mailing Address - Street 2:SUITE 7
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-3455
Mailing Address - Country:US
Mailing Address - Phone:502-423-7822
Mailing Address - Fax:502-423-7830
Practice Address - Street 1:6520 GLENRIDGE PARK PL
Practice Address - Street 2:SUITE 7
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-3455
Practice Address - Country:US
Practice Address - Phone:502-423-7822
Practice Address - Fax:502-423-7830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-23
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY85881223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty