Healthcare Provider Details

I. General information

NPI: 1386692184
Provider Name (Legal Business Name): CENTRE ORAL & FACIAL SURGERY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 04/18/2024
Certification Date: 04/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

474 WINDMERE DR SUITE 202
STATE COLLEGE PA
16801-7668
US

IV. Provider business mailing address

474 WINDMERE DR STE 202
STATE COLLEGE PA
16801-7643
US

V. Phone/Fax

Practice location:
  • Phone: 814-235-7700
  • Fax: 814-235-7633
Mailing address:
  • Phone: 814-235-7700
  • Fax: 814-235-7633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS029616L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberMD073230L
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License NumberMD073230L
License Number StatePA

VIII. Authorized Official

Name: GREGORY F KEWITT
Title or Position: OWNER/PRESIDENT
Credential: DMD, MD
Phone: 814-235-7700