Healthcare Provider Details

I. General information

NPI: 1831962323
Provider Name (Legal Business Name): WYOMING VALLEY ORAL SURGERY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2023
Last Update Date: 11/06/2023
Certification Date: 11/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 3RD AVE STE 1
KINGSTON PA
18704-5806
US

IV. Provider business mailing address

550 3RD AVE STE 1
KINGSTON PA
18704-5806
US

V. Phone/Fax

Practice location:
  • Phone: 570-288-9070
  • Fax: 570-288-4201
Mailing address:
  • Phone: 570-288-9070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. BRIAN MITCHELL
Title or Position: OWNER
Credential: DDS
Phone: 570-288-9070