Provider Demographics
NPI:1972579183
Name:MAXILLOFACIAL SURGEONS, LTD.
Entity Type:Organization
Organization Name:MAXILLOFACIAL SURGEONS, LTD.
Other - Org Name:MSL FACIAL & ORAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:R
Authorized Official - Last Name:PETITO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:401-739-5500
Mailing Address - Street 1:243 JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02888-3818
Mailing Address - Country:US
Mailing Address - Phone:401-739-5500
Mailing Address - Fax:401-738-1550
Practice Address - Street 1:243 JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02888-3818
Practice Address - Country:US
Practice Address - Phone:401-739-5500
Practice Address - Fax:401-738-1550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9008578Medicaid