1861920068 NPI number — MOFS-CT ORAL FACIAL SURGERY LLC

Table of content: (NPI 1861920068)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861920068 NPI number — MOFS-CT ORAL FACIAL SURGERY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOFS-CT 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:
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:
1861920068
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/01/2017
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:
203-998-7470
Provider Business Mailing Address Fax Number:
212-202-6447

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 BOULDER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OLD GREENWICH
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06870-1420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-990-3300
Provider Business Practice Location Address Fax Number:
212-202-6447
Provider Enumeration Date:
06/01/2017

Additional Information

Authorized Official

Authorized Official Last Name:
BODEY
Authorized Official First Name:
JANET
Authorized Official Middle Name:
C
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
203-998-7470

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  9973 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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