Provider Demographics
NPI:1700956273
Name:ADVANCED ORAL & MAXILLOFACIAL SURGERY LTD.
Entity Type:Organization
Organization Name:ADVANCED ORAL & MAXILLOFACIAL SURGERY LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLF
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-941-3400
Mailing Address - Street 1:533 W NORTH AVE.
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-2100
Mailing Address - Country:US
Mailing Address - Phone:630-941-3400
Mailing Address - Fax:630-941-3421
Practice Address - Street 1:533 W NORTH AVE.
Practice Address - Street 2:SUITE 200
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-2100
Practice Address - Country:US
Practice Address - Phone:630-941-3400
Practice Address - Fax:630-941-3421
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCED ORAL AND MAXILLOFACIAL SURGERY LTD.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-09
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223S0112X
IL060.0038991223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
216566Medicare UPIN