Healthcare Provider Details

I. General information

NPI: 1447227301
Provider Name (Legal Business Name): TUSCARAWAS ORAL & MAXILLOFACIAL SURGERY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 02/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1456 KADERLY ST NW
NEW PHILADELPHIA OH
44663-1243
US

IV. Provider business mailing address

1456 KADERLY ST NW
NEW PHILADELPHIA OH
44663-1243
US

V. Phone/Fax

Practice location:
  • Phone: 330-364-8665
  • Fax: 330-364-8667
Mailing address:
  • Phone: 330-364-8665
  • Fax: 330-364-8667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number StateOH

VIII. Authorized Official

Name: DR. C. RANDALL DOAN
Title or Position: PRESIDENT
Credential: DDS
Phone: 330-364-8665