Basic Information
| Provider Information | |||||||||
| NPI: | 1700981180 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DREXEL UNIVERSITY | ||||||||
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| OtherOrganizationName: | DREXEL ORAL & MAXILLOFACIAL SURGERY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 CHERRY ST | ||||||||
| Address2: | SUITE 11511 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191021320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152557822 | ||||||||
| FaxNumber: | 2152557825 | ||||||||
| Practice Location | |||||||||
| Address1: | 207 N BROAD ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191071500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155610562 | ||||||||
| FaxNumber: | 2155610427 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 05/27/2014 | ||||||||
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| AuthorizedOfficialLastName: | JANIEC | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PAYER CONTRACTING | ||||||||
| AuthorizedOfficialTelephone: | 2152557766 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
No ID Information.