NPIMap

Organization Active NPI

Blue Ridge Oral Surgery, Inc.

  • Oral and Maxillofacial Surgery (Dentist)
  • Fishersville, VA
National Provider Identifier
1710013446
Registry record updated Jul 10, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X
License
0438000220 Issued in VA
Legal business name
BLUE RIDGE ORAL SURGERY, INC.
Practice address
54 S. Medical Park Drive
Fishersville, VA 22939-2333
Phone
(540) 886-2956
Fax
(540) 886-2284
NPI assigned
Feb 26, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 10, 2013

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

Authorized official

Name
Matthew Todd Brandt, D.D.S., M.D.NPI 1942308259
Title
President
Phone
(540) 886-2956

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 3

Specialty (taxonomy)CodeLicenseStatePrimary
Oral and Maxillofacial Surgery (Dentist)Group: 193200000X MULTI-SPECIALTY GROUP 1223S0112X 0438000074 VA
Oral and Maxillofacial Surgery (Dentist)Group: 193200000X MULTI-SPECIALTY GROUP 1223S0112X 0438000220 VA Primary
Oral and Maxillofacial Surgery (Dentist)Group: 193200000X MULTI-SPECIALTY GROUP 1223S0112X 0401410707 VA

Addresses

Primary practice location

54 S. Medical Park Drive
Fishersville, VA 22939-2333

Mailing address

54 S. Medical Park Drive
Fishersville, VA 22939-2333
Phone (540) 886-2956

Other identifiers 2

IdentifierTypeStateIssuer
11605304OtherCAQH
9198564MedicaidVA

Other names 1

  • Blue Ridge Oral & Maxillofacial Surgery Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20080701000032 VA Part B Supplier - Clinic/Group Practice 5496827834 Receives reassigned benefits from 6 practitioners
Practice locations: Fishersville, VA; Lexington, VA

National Provider Directory

National Provider Directory

Locations

54 S Medical Park Dr
Fishersville, VA 22939
Phone (540) 886-2956

Practitioners & affiliated clinicians

Practitioners 10

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": "1172448000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1373414400000",
    "number": "1710013446",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "54 S. MEDICAL PARK DRIVE",
            "city": "FISHERSVILLE",
            "state": "VA",
            "postal_code": "229392333",
            "telephone_number": "540-886-2956",
            "fax_number": "540-886-2284"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "54 S. MEDICAL PARK DRIVE",
            "city": "FISHERSVILLE",
            "state": "VA",
            "postal_code": "229392333",
            "telephone_number": "540-886-2956",
            "fax_number": "540-886-2284"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BLUE RIDGE ORAL SURGERY, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-02-26",
        "last_updated": "2013-07-10",
        "status": "A",
        "authorized_official_last_name": "BRANDT",
        "authorized_official_first_name": "MATTHEW",
        "authorized_official_middle_name": "TODD",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "540-886-2956",
        "authorized_official_credential": "D.D.S., M.D."
    },
    "taxonomies": [
        {
            "code": "1223S0112X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "VA",
            "license": "0438000074",
            "primary": false
        },
        {
            "code": "1223S0112X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "VA",
            "license": "0438000220",
            "primary": true
        },
        {
            "code": "1223S0112X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "VA",
            "license": "0401410707",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CAQH",
            "identifier": "11605304",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "9198564",
            "state": "VA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Blue Ridge Oral & Maxillofacial Surgery",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Fishersville, VA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 10, 2013; 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.