1457417495 NPI number — ORAL & MAXILLOFACIAL ASSOC OF NUTLEY

Table of content: (NPI 1457417495)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457417495 NPI number — ORAL & MAXILLOFACIAL ASSOC OF NUTLEY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ORAL & MAXILLOFACIAL ASSOC OF NUTLEY
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:
1457417495
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/04/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
187 WASHINGTON AVENUE
Provider Second Line Business Mailing Address:
SUITE 1B
Provider Business Mailing Address City Name:
NUTLEY
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07110
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-667-5844
Provider Business Mailing Address Fax Number:
973-667-6653

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
187 WASHINGTON AVENUE
Provider Second Line Business Practice Location Address:
SUITE 1B
Provider Business Practice Location Address City Name:
NUTLEY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-667-5844
Provider Business Practice Location Address Fax Number:
973-667-6653
Provider Enumeration Date:
12/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ECHO
Authorized Official First Name:
PHILIP
Authorized Official Middle Name:
M
Authorized Official Title or Position:
ORAL SURGEON
Authorized Official Telephone Number:
973-667-5844

Provider Taxonomy Codes

  • Taxonomy code: 204E00000X , with the licence number:  D1017058 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 204E00000X , with the licence number: D1016959 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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