Provider Demographics
NPI:1356349591
Name:ORAL & MAXILLOFACIAL SURGERY ASSOCIATES PA
Entity type:Organization
Organization Name:ORAL & MAXILLOFACIAL SURGERY ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:BECKY
Authorized Official - Middle Name:
Authorized Official - Last Name:COLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-479-0707
Mailing Address - Street 1:2823 N DUKE ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-2621
Mailing Address - Country:US
Mailing Address - Phone:919-479-0707
Mailing Address - Fax:919-479-5435
Practice Address - Street 1:2823 N DUKE ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2621
Practice Address - Country:US
Practice Address - Phone:919-479-0707
Practice Address - Fax:919-479-5435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC32131223S0112X
NC47831223S0112X
NC43441223S0112X
NC96000581223S0112X
NC54711223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8902006Medicaid
NC02006OtherBCBS GROUP ID
NC1131Medicare ID - Type UnspecifiedGROUP ID NUMBER