Healthcare Provider Details

I. General information

NPI: 1063549236
Provider Name (Legal Business Name): MILL CREEK ORAL & MAXILLOFACIAL SURGERY ASSOCIATES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 01/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5437 MAHONING AVE STE 12
AUSTINTOWN OH
44515-2421
US

IV. Provider business mailing address

5437 MAHONING AVE SUITE 12
AUSTINTOWN OH
44515-2437
US

V. Phone/Fax

Practice location:
  • Phone: 330-792-2501
  • Fax: 330-792-9249
Mailing address:
  • Phone: 330-792-2501
  • Fax: 330-792-9249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number204E0000X
License Number StateOH

VIII. Authorized Official

Name: DR. MARK L BILLY
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 330-792-2501