Healthcare Provider Details

I. General information

NPI: 1104359959
Provider Name (Legal Business Name): APPALACHIAN ORAL SURGERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2017
Last Update Date: 04/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3433 UNIVERSITY AVE SUITE 1
MORGANTOWN WV
26505-3052
US

IV. Provider business mailing address

3433 UNIVERSITY AVE SUITE 1
MORGANTOWN WV
26505-3052
US

V. Phone/Fax

Practice location:
  • Phone: 304-322-4532
  • Fax:
Mailing address:
  • Phone: 304-322-4532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number4011
License Number StateWV

VIII. Authorized Official

Name: DR. MATTHEW ELWOOD KOEPKE
Title or Position: MEMBER
Credential: DDS
Phone: 304-904-7145