Provider Demographics
NPI:1952356487
Name:NIAMTU & ALEXANDER ORAL & MAXILLOFACIAL SURGERY PC
Entity Type:Organization
Organization Name:NIAMTU & ALEXANDER ORAL & MAXILLOFACIAL SURGERY PC
Other - Org Name:VIRGINIA ORAL & FACIAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROJECT COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:MARIE PITKIN
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-532-0002
Mailing Address - Street 1:11545 A NUCKOLS ROAD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-5666
Mailing Address - Country:US
Mailing Address - Phone:804-673-8061
Mailing Address - Fax:804-673-5644
Practice Address - Street 1:130 TOWNE CENTER WEST BOULEVARD
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23233-2323
Practice Address - Country:US
Practice Address - Phone:804-270-5028
Practice Address - Fax:804-747-3599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC01364Medicare PIN