Healthcare Provider Details

I. General information

NPI: 1649848458
Provider Name (Legal Business Name): FAYETTEVILLE-MANLIUS ORAL SURGERY, P.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2021
Last Update Date: 06/16/2021
Certification Date: 06/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8240 CAZENOVIA RD STE 60
MANLIUS NY
13104-8814
US

IV. Provider business mailing address

8240 CAZENOVIA RD STE 60
MANLIUS NY
13104-8814
US

V. Phone/Fax

Practice location:
  • Phone: 315-692-0449
  • Fax: 315-692-6546
Mailing address:
  • Phone: 315-692-0449
  • Fax: 315-692-6546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. EDIOUS KWAIPA ELLIOT
Title or Position: PRESIDENT
Credential: DMD
Phone: 315-692-0449