Healthcare Provider Details

I. General information

NPI: 1104249226
Provider Name (Legal Business Name): GARDEN STATE ORAL & MAXILLOFACIAL SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2014
Last Update Date: 01/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BROADWAY SUITE 101
ELMWOOD PARK NJ
07407-1842
US

IV. Provider business mailing address

1 BROADWAY SUITE 101
ELMWOOD PARK NJ
07407-1842
US

V. Phone/Fax

Practice location:
  • Phone: 201-794-3344
  • Fax: 201-794-0454
Mailing address:
  • Phone: 201-794-3344
  • Fax: 201-794-0454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDI21870
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDI15847
License Number StateNJ

VIII. Authorized Official

Name: DR. STUART KATZ
Title or Position: PRESIDENT
Credential: DMD
Phone: 201-794-3344