Provider Demographics
NPI:1912951138
Name:MAINLINE CENTER FOR ORAL & FACIAL SURGERY LTD
Entity Type:Organization
Organization Name:MAINLINE CENTER FOR ORAL & FACIAL SURGERY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:M
Authorized Official - Last Name:RAMBO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:610-644-6497
Mailing Address - Street 1:21 INDUSTRIAL BLVD
Mailing Address - Street 2:#100
Mailing Address - City:PAOLI
Mailing Address - State:PA
Mailing Address - Zip Code:19301
Mailing Address - Country:US
Mailing Address - Phone:610-644-6497
Mailing Address - Fax:610-644-6622
Practice Address - Street 1:21 INDUSTRIAL BLVD
Practice Address - Street 2:#100
Practice Address - City:PAOLI
Practice Address - State:PA
Practice Address - Zip Code:19301
Practice Address - Country:US
Practice Address - Phone:610-644-6497
Practice Address - Fax:610-644-6622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS017526L1223S0112X
PADS023677L1223S0112X
PADS0277729L1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0089457000OtherIBC
PA151610OtherHIGHMARK
PA151610OtherHIGHMARK