Healthcare Provider Details

I. General information

NPI: 1518670165
Provider Name (Legal Business Name): KEYSTONE ORAL SURGERY ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2022
Last Update Date: 02/05/2023
Certification Date: 02/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 BALDWIN BLVD STE 95
SHAMOKIN DAM PA
17876-9520
US

IV. Provider business mailing address

78 WINDSOR RD
BELLE MEAD NJ
08502-5851
US

V. Phone/Fax

Practice location:
  • Phone: 570-884-8321
  • Fax: 570-256-1772
Mailing address:
  • Phone: 267-809-2364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. PRANATHI REDDY
Title or Position: PRESIDENT
Credential: DDS
Phone: 570-884-8321