Provider Demographics
NPI:1306066683
Name:ADVANCED ORAL AND FACIAL SURGERY OF THE MAIN LINE, P.C.
Entity type:Organization
Organization Name:ADVANCED ORAL AND FACIAL SURGERY OF THE MAIN LINE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GODFREY
Authorized Official - Middle Name:JOEL
Authorized Official - Last Name:FUNARI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:610-688-6683
Mailing Address - Street 1:223 LANCASTER AVENUE
Mailing Address - Street 2:
Mailing Address - City:DEVON
Mailing Address - State:PA
Mailing Address - Zip Code:19333-1583
Mailing Address - Country:US
Mailing Address - Phone:610-688-6683
Mailing Address - Fax:610-971-0481
Practice Address - Street 1:223 LANCASTER AVENUE
Practice Address - Street 2:
Practice Address - City:DEVON
Practice Address - State:PA
Practice Address - Zip Code:19333-1583
Practice Address - Country:US
Practice Address - Phone:610-688-6683
Practice Address - Fax:610-971-0481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-27
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS023425L261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1720009863OtherNPI