Provider Demographics
NPI:1386625366
Name:ASSOCIATES IN ORAL & MAXILLOFACIAL SURGERY
Entity type:Organization
Organization Name:ASSOCIATES IN ORAL & MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:BALACI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:610-373-7823
Mailing Address - Street 1:955 BERKSHINE BLVD
Mailing Address - Street 2:STE 104
Mailing Address - City:WYOMISSING
Mailing Address - State:PA
Mailing Address - Zip Code:19610
Mailing Address - Country:US
Mailing Address - Phone:610-373-7823
Mailing Address - Fax:610-373-5590
Practice Address - Street 1:955 BERKSHINE BLVD
Practice Address - Street 2:STE 104
Practice Address - City:WYOMISSING
Practice Address - State:PA
Practice Address - Zip Code:19610
Practice Address - Country:US
Practice Address - Phone:610-373-7823
Practice Address - Fax:610-373-5590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-08
Last Update Date:2010-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA02747200OtherCAPITAL BLUE CROSS
PA0016251970003Medicaid
PA2208314OtherAETNA
PA02747200OtherCAPITAL BLUE CROSS