Provider Demographics
NPI:1871613539
Name:GREAT BAY ORAL SURGERY ASSOCIATES PA
Entity type:Organization
Organization Name:GREAT BAY ORAL SURGERY ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINSTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:S
Authorized Official - Last Name:SCARAMELLA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:603-692-6598
Mailing Address - Street 1:259 ROUTE 108
Mailing Address - Street 2:
Mailing Address - City:SOMERSWORTH
Mailing Address - State:NH
Mailing Address - Zip Code:03878-1512
Mailing Address - Country:US
Mailing Address - Phone:603-692-6598
Mailing Address - Fax:603-692-6935
Practice Address - Street 1:259 ROUTE 108
Practice Address - Street 2:
Practice Address - City:SOMERSWORTH
Practice Address - State:NH
Practice Address - Zip Code:03878-1512
Practice Address - Country:US
Practice Address - Phone:603-692-6598
Practice Address - Fax:603-692-6935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30010615Medicaid
NHRE4597Medicare ID - Type Unspecified