Provider Demographics
NPI:1538391214
Name:MAYFLOWER ORAL AND MAXILLOFACIAL SURGERY PLLC
Entity type:Organization
Organization Name:MAYFLOWER ORAL AND MAXILLOFACIAL SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:C
Authorized Official - Last Name:VEGA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-848-7974
Mailing Address - Street 1:675 PARAMOUNT DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:RAYNHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02767-5416
Mailing Address - Country:US
Mailing Address - Phone:405-848-7974
Mailing Address - Fax:405-848-0033
Practice Address - Street 1:5600 N MAY AVE
Practice Address - Street 2:SUITE 250
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-3973
Practice Address - Country:US
Practice Address - Phone:405-848-7974
Practice Address - Fax:405-848-0033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-14
Last Update Date:2009-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18551121223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty