Provider Demographics
NPI:1811059892
Name:NORTHERN ORAL & MAXILLOFACIAL SURGERY SERVICES. P.C.
Entity type:Organization
Organization Name:NORTHERN ORAL & MAXILLOFACIAL SURGERY SERVICES. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:WAY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:315-782-3101
Mailing Address - Street 1:104 PADDOCK ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-3948
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:104 PADDOCK ST
Practice Address - Street 2:SUITE 103
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-3948
Practice Address - Country:US
Practice Address - Phone:315-782-3101
Practice Address - Fax:315-782-3223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY03145311223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01137613Medicaid