Healthcare Provider Details

I. General information

NPI: 1154860120
Provider Name (Legal Business Name): PROUSI ORAL & FACIAL SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2017
Last Update Date: 02/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 MOUNT HOLLY RD BUILDING 500
BURLINGTON TOWNSHIP NJ
08016-4722
US

IV. Provider business mailing address

1900 MOUNT HOLLY RD BUILDING 500
BURLINGTON TOWNSHIP NJ
08016-4722
US

V. Phone/Fax

Practice location:
  • Phone: 609-526-8650
  • Fax: 609-526-8640
Mailing address:
  • Phone: 609-526-8650
  • Fax: 609-526-8640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number22DI02541600
License Number StateNJ

VIII. Authorized Official

Name: ANTHONY PROUSI
Title or Position: OWNER / SURGEON
Credential: DDS, MD
Phone: 609-526-8650