Healthcare Provider Details

I. General information

NPI: 1457417495
Provider Name (Legal Business Name): ORAL & MAXILLOFACIAL ASSOC OF NUTLEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 09/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

187 WASHINGTON AVENUE SUITE 1B
NUTLEY NJ
07110
US

IV. Provider business mailing address

187 WASHINGTON AVENUE SUITE 1B
NUTLEY NJ
07110
US

V. Phone/Fax

Practice location:
  • Phone: 973-667-5844
  • Fax: 973-667-6653
Mailing address:
  • Phone: 973-667-5844
  • Fax: 973-667-6653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberD1017058
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberD1016959
License Number StateNJ

VIII. Authorized Official

Name: DR. PHILIP M ECHO
Title or Position: ORAL SURGEON
Credential: DMD
Phone: 973-667-5844