Healthcare Provider Details

I. General information

NPI: 1912468463
Provider Name (Legal Business Name): PROVIDENCE ORAL SURGERY AND DENTAL IMPLANT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2019
Last Update Date: 10/26/2021
Certification Date: 10/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 WAXHAW PROFESSIONAL PARK DR STE G
WAXHAW NC
28173-5024
US

IV. Provider business mailing address

102 WAXHAW PROFESSIONAL PARK DR STE G
WAXHAW NC
28173-5024
US

V. Phone/Fax

Practice location:
  • Phone: 732-547-9101
  • Fax:
Mailing address:
  • Phone: 704-289-8819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. JAMES PARELLI
Title or Position: ORAL SURGEON/OWNER
Credential: DMD, MD
Phone: 704-289-8819