Healthcare Provider Details

I. General information

NPI: 1912951138
Provider Name (Legal Business Name): MAINLINE CENTER FOR ORAL & FACIAL SURGERY LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 INDUSTRIAL BLVD #100
PAOLI PA
19301
US

IV. Provider business mailing address

21 INDUSTRIAL BLVD #100
PAOLI PA
19301
US

V. Phone/Fax

Practice location:
  • Phone: 610-644-6497
  • Fax: 610-644-6622
Mailing address:
  • Phone: 610-644-6497
  • Fax: 610-644-6622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS017526L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS023677L
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS0277729L
License Number StatePA

VIII. Authorized Official

Name: DR. HENRY M RAMBO
Title or Position: CEO PRESIDENT
Credential: DDS
Phone: 610-644-6497