Provider Demographics
NPI:1679547707
Name:INNOVATIVE IMPLANT & ORAL SURGERY PC
Entity type:Organization
Organization Name:INNOVATIVE IMPLANT & ORAL SURGERY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:ROBYN
Authorized Official - Last Name:LODISE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-322-7810
Mailing Address - Street 1:1300 BRIDGETOWN PIKE
Mailing Address - Street 2:
Mailing Address - City:FEASTERVILLE TREVOSE
Mailing Address - State:PA
Mailing Address - Zip Code:19053-4326
Mailing Address - Country:US
Mailing Address - Phone:215-322-7810
Mailing Address - Fax:215-322-7832
Practice Address - Street 1:1300 BRIDGETOWN PIKE
Practice Address - Street 2:
Practice Address - City:FEASTERVILLE TREVOSE
Practice Address - State:PA
Practice Address - Zip Code:19053-4326
Practice Address - Country:US
Practice Address - Phone:215-322-7810
Practice Address - Fax:215-322-7832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-15
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS017304L174400000X
PADS030984L174400000X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1615888OtherSALIN BLUE SHIELD
PA0547613000OtherKEYST GROUP#
PA4437OtherAETNA NISSMAN
PA161558OtherNISSMAN BLUE SHIELD
PA747908OtherBLUE SHIELD GROUP#
PA4437OtherAETNA NISSMAN
PA747908OtherBLUE SHIELD GROUP#
PA084162Medicare ID - Type UnspecifiedSALIN
PA0547613000OtherKEYST GROUP#