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General NPI Number Information
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NPI Number | 1477567782
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Entity Type | Organization
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Legal Business Name | BALA INSTITUTE OF ORAL SURGERY
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Dates
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Enumeration Date | 07/29/2006
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Last Update Date | 03/04/2022
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Provider Practice Location Address
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Address Line | 15 PRESIDENTIAL BLVD SUITE 301
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City | BALA CYNWYD
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State | PA
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Zip | 19004-1006
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Country | US
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Telephone | 610-667-6161
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Fax | 610-617-9275
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Provider Business Mailing Address
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Address Line | 15 N PRESIDENTIAL BOULEVARD SUITE 301
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City | BALA CYNWYD
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State | PA
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Zip | 19004
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Country | US
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Telephone | 610-667-6161
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Fax | 610-617-9275
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | LISA WAXMAN
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Credential |
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Telephone | 484-680-6405
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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 | DS023126L
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License Number State | PA
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