Provider Demographics
NPI:1386692184
Name:CENTRE ORAL & FACIAL SURGERY, P.C.
Entity type:Organization
Organization Name:CENTRE ORAL & FACIAL SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:F
Authorized Official - Last Name:KEWITT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:814-235-7700
Mailing Address - Street 1:474 WINDMERE DR STE 202
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801-7643
Mailing Address - Country:US
Mailing Address - Phone:814-235-7700
Mailing Address - Fax:814-235-7633
Practice Address - Street 1:474 WINDMERE DR
Practice Address - Street 2:SUITE 202
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-7668
Practice Address - Country:US
Practice Address - Phone:814-235-7700
Practice Address - Fax:814-235-7633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS029616L1223S0112X
PAMD073230L204E00000X, 2082S0099X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and NeckGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAKE1304618OtherHIGHMARK BLUE SHIELD
PAH70326Medicare UPIN
PAKE1304618OtherHIGHMARK BLUE SHIELD
PA062359Medicare ID - Type UnspecifiedMEDICARE GROUP#