1699833566 NPI number — SOUTH BERGEN ORAL SURGERY PA

Table of content: (NPI 1699833566)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699833566 NPI number — SOUTH BERGEN ORAL SURGERY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH BERGEN ORAL SURGERY PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699833566
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
422 STUYVESANT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LYNDHURST
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07071
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-935-4577
Provider Business Mailing Address Fax Number:
201-935-8893

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
422 STUYVESANT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LYNDHURST
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07071
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-935-4577
Provider Business Practice Location Address Fax Number:
201-935-8893
Provider Enumeration Date:
12/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DILASCIO
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PRESIDENT SO BERGEN ORAL SURGERY PA
Authorized Official Telephone Number:
201-935-4577

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  9227 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223S0112X , with the licence number: 9218 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 058001 . This is a "MEDICARE PIN" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com