Provider Demographics
NPI:1144509209
Name:MASSACHUSETTS GENERAL HOSPITAL ORAL & MAXILLOFACIAL SURGERY
Entity type:Organization
Organization Name:MASSACHUSETTS GENERAL HOSPITAL ORAL & MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF
Authorized Official - Prefix:DR
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:KABAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-726-2740
Mailing Address - Street 1:55 FRUIT ST
Mailing Address - Street 2:WANG AMBULATORY BUILDING SUITE 230
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2621
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:WANG AMBULATORY BUILDING SUITE 230
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-726-8222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-08
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QS0112X
MAP-36801282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110008955/BMedicaid
MA110008955/BMedicaid
TX2271Medicare PIN