Provider Demographics
NPI:1023388196
Name:OASIS ORAL SURGERY LLC
Entity type:Organization
Organization Name:OASIS ORAL SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRYANT
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-904-8951
Mailing Address - Street 1:9501 ROOSEVELT BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19114-1025
Mailing Address - Country:US
Mailing Address - Phone:215-904-8951
Mailing Address - Fax:
Practice Address - Street 1:9501 ROOSEVELT BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-1025
Practice Address - Country:US
Practice Address - Phone:215-904-8951
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-06
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0381521223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102496758Medicaid