Provider Demographics
NPI:1952411720
Name:SOUTH PHILADELPHIA ORAL AND MAXILLOFACIAL SURGERY ASSOCIATES PC
Entity Type:Organization
Organization Name:SOUTH PHILADELPHIA ORAL AND MAXILLOFACIAL SURGERY ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:WOHAR
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:215-389-2511
Mailing Address - Street 1:1613 SOUTH BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PHILIDELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19148
Mailing Address - Country:US
Mailing Address - Phone:215-389-2511
Mailing Address - Fax:215-389-0334
Practice Address - Street 1:1613 SOUTH BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILIDELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148
Practice Address - Country:US
Practice Address - Phone:215-389-2511
Practice Address - Fax:215-389-0334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0317930000OtherKEYSTONE HEALTH PLAN EAST
PA117949OtherINDEPENCE BLUE CROSS PERS