Healthcare Provider Details

I. General information

NPI: 1164806972
Provider Name (Legal Business Name): NORTHEAST REGIONAL CENTER FOR ORAL & MAXILLOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2015
Last Update Date: 07/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 E MAIN ST
LITTLE FALLS NJ
07424-5604
US

IV. Provider business mailing address

50 E MAIN ST
LITTLE FALLS NJ
07424-5604
US

V. Phone/Fax

Practice location:
  • Phone: 973-256-0103
  • Fax: 973-256-8066
Mailing address:
  • Phone: 973-256-0103
  • Fax: 973-256-8066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDI18430
License Number StateNJ

VIII. Authorized Official

Name: DR. RICHARD PATRICK SZUMITA
Title or Position: OWNER
Credential: D.D.S.
Phone: 973-256-0103