Provider Demographics
NPI:1043496599
Name:MONTCO ORAL AND MAXILLOFACIAL SURGERY
Entity type:Organization
Organization Name:MONTCO ORAL AND MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:LUKAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-489-0525
Mailing Address - Street 1:545 W MAIN ST
Mailing Address - Street 2:SUITE 24
Mailing Address - City:TRAPPE
Mailing Address - State:PA
Mailing Address - Zip Code:19426-1981
Mailing Address - Country:US
Mailing Address - Phone:610-489-0525
Mailing Address - Fax:610-489-4720
Practice Address - Street 1:545 W MAIN ST
Practice Address - Street 2:SUITE 24
Practice Address - City:TRAPPE
Practice Address - State:PA
Practice Address - Zip Code:19426-1981
Practice Address - Country:US
Practice Address - Phone:610-489-0525
Practice Address - Fax:610-489-4720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-15
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0243051223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA500298Medicare PIN