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General NPI Number Information
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NPI Number | 1962178970
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Entity Type | Organization
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Legal Business Name | COMMUNITY ORAL AND MAXILLOFACIAL SURGERY, LLC
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Dates
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Enumeration Date | 08/19/2021
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Last Update Date | 11/29/2022
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Provider Practice Location Address
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Address Line | 408 W FLORIDA ST STE 105
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City | MILWAUKEE
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State | WI
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Zip | 53204-1509
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Country | US
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Telephone | 401-401-4141
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Fax |
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Provider Business Mailing Address
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Address Line | 408 W FLORIDA ST STE 105
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City | MILWAUKEE
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State | WI
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Zip | 53204-1509
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Country | US
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Telephone | 414-810-1707
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | RUBA KHADER
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Credential | BDS
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Telephone | 414-810-1707
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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 |
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License Number State |
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