=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649848458
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAYETTEVILLE-MANLIUS ORAL SURGERY, P.C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2021
-----------------------------------------------------
Last Update Date | 06/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8240 CAZENOVIA RD STE 60
-----------------------------------------------------
City | MANLIUS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13104-8814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-692-0449
-----------------------------------------------------
Fax | 315-692-6546
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8240 CAZENOVIA RD STE 60
-----------------------------------------------------
City | MANLIUS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13104-8814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-692-0449
-----------------------------------------------------
Fax | 315-692-6546
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. EDIOUS KWAIPA ELLIOT
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 315-692-0449
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------