Provider Demographics
NPI:1740088608
Name:PROFESSIONAL ORAL SURGERY ALLIANCE OF UPSTATE NEW YORK, PLLC
Entity type:Organization
Organization Name:PROFESSIONAL ORAL SURGERY ALLIANCE OF UPSTATE NEW YORK, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:KAYLA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-698-2474
Mailing Address - Street 1:125 ENTERPRISE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15275-1223
Mailing Address - Country:US
Mailing Address - Phone:724-698-2500
Mailing Address - Fax:
Practice Address - Street 1:4708 TRANSIT RD
Practice Address - Street 2:
Practice Address - City:DEPEW
Practice Address - State:NY
Practice Address - Zip Code:14043-4862
Practice Address - Country:US
Practice Address - Phone:716-668-3315
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-06
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty