Provider Demographics
NPI:1194963900
Name:POCONO ORAL SURGERY PC
Entity type:Organization
Organization Name:POCONO ORAL SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:MONTO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD,MD
Authorized Official - Phone:570-253-4000
Mailing Address - Street 1:1095 TEXAS PALMYRA HWY
Mailing Address - Street 2:
Mailing Address - City:HONESDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18431-7687
Mailing Address - Country:US
Mailing Address - Phone:570-253-4000
Mailing Address - Fax:570-253-8977
Practice Address - Street 1:1095 TEXAS PALMYRA HWY
Practice Address - Street 2:
Practice Address - City:HONESDALE
Practice Address - State:PA
Practice Address - Zip Code:18431-7687
Practice Address - Country:US
Practice Address - Phone:570-253-4000
Practice Address - Fax:570-253-8977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-02
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0352871223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAU74511Medicare UPIN