Charlottesville Oral Surgery and Dental Implant Center, LLC

Primary specialty

Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X

License

0438000261 Issued in VA

Legal business name

CHARLOTTESVILLE ORAL SURGERY AND DENTAL IMPLANT CENTER, LLC

Practice address

1415 Rolkin CT Ste 101
Charlottesville, VA 22911-3643

Phone

(434) 295-0911

NPI assigned

Jan 20, 2009

Organization subpart

No

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

Authorized official

Name

Dr. Carlos Ibanez, DDSNPI 1154327005

Title

President

Phone

(434) 823-7711

Specialties & licenses 1

Addresses

Other identifiers 1

Locations

Practitioners 1

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

• Carlos R Ibanez, DDS

  • Oral and Maxillofacial Surgery (Dentist)
  • Charlottesville, VA
  • NPI 1154327005
  NPD (past) Authorized official

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

{
    "created_epoch": "1232409600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1542153600000",
    "number": "1972740454",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1415 ROLKIN CT STE 101",
            "city": "CHARLOTTESVILLE",
            "state": "VA",
            "postal_code": "229113643",
            "telephone_number": "434-295-0911"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1415 ROLKIN CT STE 101",
            "city": "CHARLOTTESVILLE",
            "state": "VA",
            "postal_code": "229113643",
            "telephone_number": "434-295-0911"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CHARLOTTESVILLE ORAL SURGERY AND DENTAL IMPLANT CENTER, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-01-20",
        "last_updated": "2018-11-14",
        "status": "A",
        "authorized_official_last_name": "IBANEZ",
        "authorized_official_first_name": "CARLOS",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "434-823-7711",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "1223S0112X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "VA",
            "license": "0438000261",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2105438",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Oral and Maxillofacial Surgery (Dentist) in Charlottesville, VA
• Providers in Charlottesville, VA by specialty
• Oral and Maxillofacial Surgery (Dentist) in Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 14, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.