| Southeastern Pa Oral Surgery Llc | |
|
2301 E Allegheny Ave Ste 206 Philadelphia PA 19134-4427 | |
| (267) 367-5009 | |
| (267) 367-5476 |
| Full Name | Southeastern Pa Oral Surgery Llc |
|---|---|
| Speciality | Dentist |
| Location | 2301 E Allegheny Ave Ste 206, Philadelphia, Pennsylvania |
| Authorized Official Name and Position | Brian M Smith (CHAIRMAN) |
| Authorized Official Contact | 2157077138 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Southeastern Pa Oral Surgery Llc 100 E Lehigh Ave Pm2 Philadelphia PA 19125-1012 Ph: (215) 707-7138 | Southeastern Pa Oral Surgery Llc 2301 E Allegheny Ave Ste 206 Philadelphia PA 19134-4427 Ph: (267) 367-5009 |
| NPI Number | 1073641148 |
|---|---|
| Provider Enumeration Date | 03/01/2007 |
| Last Update Date | 08/13/2020 |
| Medicare PECOS PAC ID | 3072567197 |
|---|---|
| Medicare Enrollment ID | O20050310000642 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1073641148 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223S0112X | Dentist - Oral And Maxillofacial Surgery | (* (Not Available)) | Primary |
| Provider Name | Joseph P Mulligan |
|---|---|
| Provider Type | Practitioner - Oral Surgery |
| Provider Identifiers | NPI Number: 1225045594 PECOS PAC ID: 6507842671 Enrollment ID: I20050315000739 |
| Provider Name | Samer M Abdelsamie |
|---|---|
| Provider Type | Practitioner - Maxillofacial Surgery |
| Provider Identifiers | NPI Number: 1366732257 PECOS PAC ID: 3577878081 Enrollment ID: I20150812008798 |
| Provider Name | Allen Fred Fielding |
|---|---|
| Provider Type | Practitioner - Oral Surgery |
| Provider Identifiers | NPI Number: 1568563070 PECOS PAC ID: 5597055186 Enrollment ID: I20160610000468 |
| Provider Name | Paul Deitrick |
|---|---|
| Provider Type | Practitioner - Maxillofacial Surgery |
| Provider Identifiers | NPI Number: 1851527600 PECOS PAC ID: 4284943606 Enrollment ID: I20160707000217 |
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