Healthcare Provider Details

I. General information

NPI: 1134240617
Provider Name (Legal Business Name): ORAL AND MAXILLO-FACIAL SURGERY ASSOC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 W TAFT RD 3M
LIVERPOOL NY
13088-3807
US

IV. Provider business mailing address

5100 W TAFT RD 3M
LIVERPOOL NY
13088-3807
US

V. Phone/Fax

Practice location:
  • Phone: 315-452-2570
  • Fax:
Mailing address:
  • Phone: 315-452-2570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. THOMAS J FALLON
Title or Position: ORAL SURGEON
Credential: D.D.S.P.C.
Phone: 315-452-2570