=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336748870
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALBANESE ORAL & MAXILLOFACIAL SURGERY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2020
-----------------------------------------------------
Last Update Date | 02/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 OLD FORGE LN STE 301
-----------------------------------------------------
City | KENNETT SQUARE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19348-1897
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-926-6001
-----------------------------------------------------
Fax | 484-926-6002
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 OLD FORGE LN STE 301
-----------------------------------------------------
City | KENNETT SQUARE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19348-1932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-926-6001
-----------------------------------------------------
Fax | 484-926-6002
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JAY ALBANESE
-----------------------------------------------------
Credential | DDS, MD
-----------------------------------------------------
Telephone | 484-926-6001
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------