Provider Demographics
NPI:1144274382
Name:COMMONWEALTH ORAL & FACIAL SURGERY, PC
Entity type:Organization
Organization Name:COMMONWEALTH ORAL & FACIAL SURGERY, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR BILLING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:GWEN
Authorized Official - Middle Name:EVA
Authorized Official - Last Name:KENNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-354-1602
Mailing Address - Street 1:PO BOX 71930
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23255-1930
Mailing Address - Country:US
Mailing Address - Phone:804-354-1600
Mailing Address - Fax:804-354-1607
Practice Address - Street 1:8503 PATTERSON AVE
Practice Address - Street 2:SUITE B
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-6442
Practice Address - Country:US
Practice Address - Phone:804-354-1600
Practice Address - Fax:804-354-1607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0135583-31223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C04968Medicare PIN
C05256Medicare PIN
C02366Medicare PIN