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General NPI Number Information
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NPI Number | 1104359959
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Entity Type | Organization
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Legal Business Name | APPALACHIAN ORAL SURGERY CENTER
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Dates
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Enumeration Date | 04/09/2017
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Last Update Date | 04/09/2017
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Provider Practice Location Address
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Address Line | 3433 UNIVERSITY AVE SUITE 1
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City | MORGANTOWN
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State | WV
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Zip | 26505-3052
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Country | US
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Telephone | 304-322-4532
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Fax |
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Provider Business Mailing Address
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Address Line | 3433 UNIVERSITY AVE SUITE 1
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City | MORGANTOWN
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State | WV
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Zip | 26505-3052
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Country | US
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Telephone | 304-322-4532
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | DR. MATTHEW ELWOOD KOEPKE
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Credential | DDS
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Telephone | 304-904-7145
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 4011
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License Number State | WV
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