Provider Demographics
NPI:1912468463
Name:PROVIDENCE ORAL SURGERY AND DENTAL IMPLANT CENTER
Entity type:Organization
Organization Name:PROVIDENCE ORAL SURGERY AND DENTAL IMPLANT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL SURGEON/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:PARELLI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:704-289-8819
Mailing Address - Street 1:102 WAXHAW PROFESSIONAL PARK DR STE G
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-5024
Mailing Address - Country:US
Mailing Address - Phone:704-289-8819
Mailing Address - Fax:
Practice Address - Street 1:102 WAXHAW PROFESSIONAL PARK DR STE G
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-5024
Practice Address - Country:US
Practice Address - Phone:732-547-9101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-27
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial SurgeryGroup - Single Specialty