1043661440 NPI number — MOFS-NJ ORAL FACIAL SURGERY LLC

Table of content: (NPI 1043661440)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043661440 NPI number — MOFS-NJ ORAL FACIAL SURGERY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOFS-NJ ORAL FACIAL SURGERY LLC
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:
1043661440
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6118 RIVERDALE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRONX
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10471-1009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
646-360-4840
Provider Business Mailing Address Fax Number:
212-202-6447

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
901 WASHINGTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOBOKEN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07030-5105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-659-1600
Provider Business Practice Location Address Fax Number:
212-202-6447
Provider Enumeration Date:
06/27/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BODEY
Authorized Official First Name:
JANET
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGEING MEMBER
Authorized Official Telephone Number:
646-360-4840

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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