Provider Demographics
NPI:1740697333
Name:ORAL FACIAL SURGERY INSTITUTE OF IL. P.C.
Entity type:Organization
Organization Name:ORAL FACIAL SURGERY INSTITUTE OF IL. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:E
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CMPE, FAADOM
Authorized Official - Phone:314-251-6725
Mailing Address - Street 1:10200 WEST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223
Mailing Address - Country:US
Mailing Address - Phone:618-397-2464
Mailing Address - Fax:618-398-4450
Practice Address - Street 1:10200 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223
Practice Address - Country:US
Practice Address - Phone:618-397-2464
Practice Address - Fax:618-398-4450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-16
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty