Healthcare Provider Details

I. General information

NPI: 1467427567
Provider Name (Legal Business Name): MEDFORD ORAL SURGERY ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 04/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

689 FELLSWAY
MEDFORD MH
02155
US

IV. Provider business mailing address

689 FELLSWAY
MEDFORD MA
02155-4931
US

V. Phone/Fax

Practice location:
  • Phone: 781-395-3100
  • Fax: 781-395-3058
Mailing address:
  • Phone: 781-395-3100
  • Fax: 781-395-3058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number13669
License Number StateMA

VIII. Authorized Official

Name: DR. LAWRENCE WILLIAM JOYCE
Title or Position: PRESIDENT
Credential: DMD
Phone: 781-395-3100