Provider Demographics
NPI:1972740454
Name:CHARLOTTESVILLE ORAL SURGERY AND DENTAL IMPLANT CENTER, LLC
Entity Type:Organization
Organization Name:CHARLOTTESVILLE ORAL SURGERY AND DENTAL IMPLANT CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:
Authorized Official - Last Name:IBANEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:434-823-7711
Mailing Address - Street 1:1415 ROLKIN CT STE 101
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22911-3643
Mailing Address - Country:US
Mailing Address - Phone:434-295-0911
Mailing Address - Fax:
Practice Address - Street 1:1415 ROLKIN CT STE 101
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-3643
Practice Address - Country:US
Practice Address - Phone:434-295-0911
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-20
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04380002611223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2105438Medicaid
CTV05838Medicare PIN