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General NPI Number Information
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NPI Number | 1912468463
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Entity Type | Organization
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Legal Business Name | PROVIDENCE ORAL SURGERY AND DENTAL IMPLANT CENTER
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Dates
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Enumeration Date | 03/27/2019
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Last Update Date | 10/26/2021
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Provider Practice Location Address
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Address Line | 102 WAXHAW PROFESSIONAL PARK DR STE G
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City | WAXHAW
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State | NC
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Zip | 28173-5024
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Country | US
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Telephone | 732-547-9101
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Fax |
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Provider Business Mailing Address
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Address Line | 102 WAXHAW PROFESSIONAL PARK DR STE G
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City | WAXHAW
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State | NC
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Zip | 28173-5024
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Country | US
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Telephone | 704-289-8819
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Fax |
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Authorized Official
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Title or Position | ORAL SURGEON/OWNER
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Name | DR. JAMES PARELLI
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Credential | DMD, MD
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Telephone | 704-289-8819
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QS0112X
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Taxonomy Name | Oral and Maxillofacial Surgery Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number |
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License Number State |
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