Provider Demographics
NPI:1649848458
Name:FAYETTEVILLE-MANLIUS ORAL SURGERY, P.C
Entity type:Organization
Organization Name:FAYETTEVILLE-MANLIUS ORAL SURGERY, P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDIOUS
Authorized Official - Middle Name:KWAIPA
Authorized Official - Last Name:ELLIOT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:315-692-0449
Mailing Address - Street 1:8240 CAZENOVIA RD STE 60
Mailing Address - Street 2:
Mailing Address - City:MANLIUS
Mailing Address - State:NY
Mailing Address - Zip Code:13104-8814
Mailing Address - Country:US
Mailing Address - Phone:315-692-0449
Mailing Address - Fax:315-692-6546
Practice Address - Street 1:8240 CAZENOVIA RD STE 60
Practice Address - Street 2:
Practice Address - City:MANLIUS
Practice Address - State:NY
Practice Address - Zip Code:13104-8814
Practice Address - Country:US
Practice Address - Phone:315-692-0449
Practice Address - Fax:315-692-6546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ163-943-4665Medicaid