1063802627 NPI number — ORAL AND IMPLANT SURGERY OF MANHATTAN, PLLC

Table of content: (NPI 1063802627)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063802627 NPI number — ORAL AND IMPLANT SURGERY OF MANHATTAN, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ORAL AND IMPLANT SURGERY OF MANHATTAN, PLLC
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:
6
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:
1063802627
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
455 W 23RD ST
Provider Second Line Business Mailing Address:
APT. 17AB
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10011-2148
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
212-752-8600
Provider Business Mailing Address Fax Number:
203-661-0155

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18 E 48TH ST
Provider Second Line Business Practice Location Address:
SUITE 1502
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10017-1014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-752-8600
Provider Business Practice Location Address Fax Number:
203-661-0155
Provider Enumeration Date:
02/03/2015

Additional Information

Authorized Official

Authorized Official Last Name:
BERGEN
Authorized Official First Name:
MICHELE
Authorized Official Middle Name:
SHOSHANA
Authorized Official Title or Position:
SOLE MEMBER
Authorized Official Telephone Number:
212-752-8600

Provider Taxonomy Codes

  • Taxonomy code: 204E00000X , with the licence number:  231685 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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