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General NPI Number Information
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NPI Number | 1336101070
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Entity Type | Organization
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Legal Business Name | CENTURY ORAL SURGERY PC
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Dates
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Enumeration Date | 04/06/2006
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Last Update Date | 10/25/2007
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Provider Practice Location Address
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Address Line | 684 NORTH HERMITAGE RD
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City | HERMITAGE
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State | PA
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Zip | 16148
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Country | US
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Telephone | 724-981-4222
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Fax | 724-981-4228
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Provider Business Mailing Address
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Address Line | 684 NORTH HERMITAGE RD
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City | HERMITAGE
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State | PA
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Zip | 16148
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Country | US
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Telephone | 724-981-4222
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Fax | 724-981-4228
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. RUSSELL THOMAS WIBLE
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Credential | DMD
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Telephone | 724-981-4222
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DS027889L
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License Number State | PA
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