Healthcare Provider Details

I. General information

NPI: 1760661789
Provider Name (Legal Business Name): WARREN ORAL AND FACIAL SURGERY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2007
Last Update Date: 10/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8893 E MARKET ST
WARREN OH
44484-2351
US

IV. Provider business mailing address

8893 E MARKET ST
WARREN OH
44484-2351
US

V. Phone/Fax

Practice location:
  • Phone: 330-856-7950
  • Fax: 330-856-1447
Mailing address:
  • Phone: 330-856-7950
  • Fax: 330-856-1447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number35075926
License Number StateOH

VIII. Authorized Official

Name: DR. JEFFREY RICHARD MCCLAIN
Title or Position: PRESIDENT
Credential: D.M.D., M.D.
Phone: 330-856-7950