NPIMap

Organization Active NPI

Delaware Valley Maxillofacial & Oral Surgery LLC

Doing business as Southeastern Pa Oral Surgery LLC

  • Oral and Maxillofacial Surgery (Dentist)
  • Philadelphia, PA
National Provider Identifier
1073641148
Registry record updated Aug 13, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X
Legal business name
DELAWARE VALLEY MAXILLOFACIAL & ORAL SURGERY LLC
Doing business as
Southeastern Pa Oral Surgery LLC
Practice address
2301 E Allegheny Ave Ste 206
Philadelphia, PA 19134-4427
Phone
(267) 367-5009
Fax
(267) 367-5476
NPI assigned
Mar 1, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 13, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Brian M Smith, DMDNPI 1811985948
Title
Chairman
Phone
(215) 707-7138

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Oral and Maxillofacial Surgery (Dentist)Group: 193400000X SINGLE SPECIALTY GROUP 1223S0112X Primary

Addresses

Primary practice location

2301 E Allegheny Ave Ste 206
Philadelphia, PA 19134-4427

Mailing address

100 E Lehigh Ave
PM2
Philadelphia, PA 19125-1012
Phone (215) 707-7138

Other practice location 1

100 E Lehigh Ave
PM2
Philadelphia, PA 19125-1012
Phone (215) 707-7138

Other names 1

  • Southeastern Pa Oral Surgery LLC Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in PA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20050310000642 PA Part B Supplier - Clinic/Group Practice 3072567197 Receives reassigned benefits from 4 practitioners
Practice locations: Philadelphia, PA

National Provider Directory

National Provider Directory

Locations

2301 E Allegheny Ave
Ste 206
Philadelphia, PA 19134
Phone (267) 367-5009

Practitioners & affiliated clinicians

Practitioners 12

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1172707200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1597276800000",
    "number": "1073641148",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "100 E LEHIGH AVE",
            "address_2": "PM2",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191251012",
            "telephone_number": "215-707-7138",
            "fax_number": "215-707-5405"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2301 E ALLEGHENY AVE STE 206",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191344427",
            "telephone_number": "267-367-5009",
            "fax_number": "267-367-5476"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "100 E Lehigh Ave",
            "address_2": "PM2",
            "address_purpose": "LOCATION",
            "city": "Philadelphia",
            "state": "PA",
            "postal_code": "191251012",
            "country_code": "US",
            "telephone_number": "215-707-7138",
            "fax_number": "215-707-5405",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "DELAWARE VALLEY MAXILLOFACIAL & ORAL SURGERY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-01",
        "last_updated": "2020-08-13",
        "certification_date": "2020-08-13",
        "status": "A",
        "authorized_official_last_name": "SMITH",
        "authorized_official_first_name": "BRIAN",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "CHAIRMAN",
        "authorized_official_telephone_number": "215-707-7138",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DMD"
    },
    "taxonomies": [
        {
            "code": "1223S0112X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Southeastern Pa Oral Surgery LLC",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Southeastern Pa Oral Surgery LLC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Philadelphia, PA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 13, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.