Provider Demographics
NPI:1831393685
Name:POCONO ORAL SURGERY
Entity type:Organization
Organization Name:POCONO ORAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RECEPTIONIST
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:NILES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-253-4000
Mailing Address - Street 1:1095 TEXAS PALMYRA HWY
Mailing Address - Street 2:SUITE M
Mailing Address - City:HONESDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18431-7672
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1095 TEXAS PALMYRA HWY
Practice Address - Street 2:SUITE M
Practice Address - City:HONESDALE
Practice Address - State:PA
Practice Address - Zip Code:18431-7672
Practice Address - Country:US
Practice Address - Phone:570-253-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-14
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0352871223P0106X
PABL58711871223P0106X
PADS020813L1223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAT28289Medicare UPIN
PA057374Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
PASTO82152Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
PAU74511Medicare UPIN