Healthcare Provider Details

I. General information

NPI: 1356349591
Provider Name (Legal Business Name): ORAL & MAXILLOFACIAL SURGERY ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 02/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2823 N DUKE ST
DURHAM NC
27704-2621
US

IV. Provider business mailing address

2823 N DUKE ST
DURHAM NC
27704-2621
US

V. Phone/Fax

Practice location:
  • Phone: 919-479-0707
  • Fax: 919-479-5435
Mailing address:
  • Phone: 919-479-0707
  • Fax: 919-479-5435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number3213
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number4783
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number4344
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number9600058
License Number StateNC
# 5
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number5471
License Number StateNC

VIII. Authorized Official

Name: BECKY COLEY
Title or Position: ADMINISTRATIVE SUPERVISOR
Credential:
Phone: 919-479-0707