NPIMap

Individual provider Active NPI

Jeffrey Samuel Wallis, D.M.D.

  • Oral and Maxillofacial Surgery (Dentist)
  • Cherry Hill, NJ
National Provider Identifier
1528371507
Registry record updated Oct 30, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X
License
22DI02571300 Issued in NJ
Practice address
17 W Ormond Ave
Cherry Hill, NJ 08002-3041
Phone
(856) 428-4445
Fax
(856) 428-4497
NPI assigned
Jul 20, 2010
Last updated
Oct 30, 2014By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Oct 30, 2014

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

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Oral and Maxillofacial Surgery (Dentist) 1223S0112X DS038160 PA
Oral and Maxillofacial Surgery (Dentist) 1223S0112X 22DI02571300 NJ Primary
Oral and Maxillofacial Surgery (Dentist) 1223S0112X 22DI02571301 NJ

Addresses

Primary practice location

17 W Ormond Ave
Cherry Hill, NJ 08002-3041

Mailing address

17 W Ormond Ave
Cherry Hill, NJ 08002-3041
Phone (856) 428-4445

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in PA
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20150608000247 PA Practitioner - Oral Surgery 7416189279 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Oral Surgery
Education
Other, 2009
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Oral and Maxillofacial Surgical AssociatesGroup PAC ID 7012990807, 6 clinicians

Practice addresses (Care Compare)

2100 N Broad St
Suite 106
Lansdale, PA 19446-1052
Phone (215) 368-8104

672 Main St
Suite a
Harleysville, PA 19438-1678
Phone (215) 256-0405

813 Bethlehem Pike
Suite 100
Erdenheim, PA 19038-8100
Phone (215) 233-2590

920 Germantown Pike
Suite 120
Plymouth Meeting, PA 19462-7401
Phone (610) 239-2495

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled

State licenses

LicenseStateTypeSpecialty
22DI02571300NJMDOral and Maxillofacial Surgery (Dentist)
22DI02571301NJMDOral and Maxillofacial Surgery (Dentist)

Practice roles

OrganizationSpecialtyStatusNew patients
Oral & Maxillofacial Surgical Associates Oral and Maxillofacial Surgery CurrentSince Jun 1, 2015 Accepting new patients

Locations

813 Bethlehem Pike
Ste 100
Erdenheim, PA 19038
Phone (215) 233-2590

672 Main St
Ste A
Harleysville, PA 19438
Phone (215) 256-0405

619 Horsham Rd
Horsham, PA 19044
Phone (215) 674-4400

2100 N Broad St
Ste 106
Lansdale, PA 19446
Phone (215) 368-8104

920 Germantown Pike
Ste 120
Plymouth Meeting, PA 19462
Phone (610) 239-2495

Organizations & group practices 1

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 26

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 26

NPI Registry JSON

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

{
    "created_epoch": "1279584000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1414627200000",
    "number": "1528371507",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "17 W ORMOND AVE",
            "city": "CHERRY HILL",
            "state": "NJ",
            "postal_code": "080023041",
            "telephone_number": "856-428-4445",
            "fax_number": "856-428-4497"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "17 W ORMOND AVE",
            "city": "CHERRY HILL",
            "state": "NJ",
            "postal_code": "080023041",
            "telephone_number": "856-428-4445",
            "fax_number": "856-428-4497"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLIS",
        "first_name": "JEFFREY",
        "middle_name": "SAMUEL",
        "name_prefix": "Dr.",
        "credential": "D.M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2010-07-20",
        "last_updated": "2014-10-30",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "PA",
            "license": "DS038160",
            "primary": false
        },
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "NJ",
            "license": "22DI02571300",
            "primary": true
        },
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "NJ",
            "license": "22DI02571301",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Cherry Hill, NJ

Sources for this page

Verify at the official NPI Registry.