Healthcare Provider Details

I. General information

NPI: 1578767463
Provider Name (Legal Business Name): WESTERN PENNSYLVANIA ORAL AND MAXILLOFACIAL SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 12/16/2019
Certification Date: 12/16/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2112 N FRANKLIN DRIVE SUITE 2
WASHINGTON PA
15301-1530
US

IV. Provider business mailing address

2112 N FRANKLIN DR SUITE 2
WASHINGTON PA
15301-5892
US

V. Phone/Fax

Practice location:
  • Phone: 724-223-0579
  • Fax:
Mailing address:
  • Phone: 724-223-0579
  • Fax: 724-223-0597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS030642L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberDA031589
License Number StatePA

VIII. Authorized Official

Name: KATHLEEN BENTLEJEWSKI
Title or Position: OFFICE MANAGER
Credential:
Phone: 724-223-0579