Healthcare Provider Details

I. General information

NPI: 1982149514
Provider Name (Legal Business Name): ORAL SURGERY PARTNERS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2017
Last Update Date: 01/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

388 PARK AVE
WORCESTER MA
01610-1025
US

IV. Provider business mailing address

5 MOUNT ROYAL AVE SUITE 300
MARLBOROUGH MA
01752-1981
US

V. Phone/Fax

Practice location:
  • Phone: 508-798-6565
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN1857191
License Number StateMA

VIII. Authorized Official

Name: JOANNE TAVANO
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 978-580-1524