MEDICARE: MAINE ORAL & MAXILLOFACIAL SURGERY ASSOCIATES, P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)

General Provider Information

NPI Number	:	1063468163
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAINE ORAL & MAXILLOFACIAL SURGERY ASSOCIATES, P.A.

Provider Business Mailing Address
First Line	:	211 MOUNT AUBURN AVENUE
Second Line	:
City	:	AUBURN
State	:	ME
Zip	:	04210-8521
Country	:	US
Telephone Number	:	207-514-7171
Fax Number	:	207-514-7177

Provider Business Practice Location Address
First Line	:	211 MOUNT AUBURN AVE
Second Line	:
City	:	AUBURN
State	:	ME
Zip	:	04210-8521
Country	:	US
Telephone Number	:	207-514-7171
Fax Number	:	207-514-7177

Authorized Official
Title or Position	:	PRESIDENT/SURGEON
Name	:	BRUCE V GALLUP
Credential	:	DMD
Telephone Number	:	207-514-7171

Provider Enumeration Date	:	05/26/2006
Last Update Date	:	07/10/2012

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