Healthcare Provider Details

I. General information

NPI: 1902542863
Provider Name (Legal Business Name): LEBANON ORAL SURGERY GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2022
Last Update Date: 05/12/2022
Certification Date: 05/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 TUCK ST STE 100
LEBANON PA
17042-7477
US

IV. Provider business mailing address

860 TUCK ST STE 100
LEBANON PA
17042-7477
US

V. Phone/Fax

Practice location:
  • Phone: 717-273-6745
  • Fax:
Mailing address:
  • Phone: 717-273-6745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ALEXANDRE BALACI
Title or Position: OWNER
Credential: DMD
Phone: 717-273-6745