Healthcare Provider Details

I. General information

NPI: 1629123229
Provider Name (Legal Business Name): MAXILLO FACIAL SURGEONS LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 W CHESTER PIKE SUITE 100
NEWTOWN SQUARE PA
19073-3704
US

IV. Provider business mailing address

3501 W CHESTER PIKE SUITE 100
NEWTOWN SQUARE PA
19073-3704
US

V. Phone/Fax

Practice location:
  • Phone: 610-353-1404
  • Fax: 610-353-1083
Mailing address:
  • Phone: 610-353-1404
  • Fax: 610-353-1083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS-016814-L
License Number StatePA

VIII. Authorized Official

Name: DR. HAROLD RUSSELL ROMESBURG
Title or Position: PRES
Credential: DDS
Phone: 616-353-1404