Healthcare Provider Details

I. General information

NPI: 1770781411
Provider Name (Legal Business Name): AESTHETIC ORAL & MAXILLOFACIAL SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 10/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

348 E MAIN ST
SOMERVILLE NJ
08876-3110
US

IV. Provider business mailing address

52 INDEPENDENCE WAY
JERSEY CITY NJ
07305-5460
US

V. Phone/Fax

Practice location:
  • Phone: 908-722-0850
  • Fax:
Mailing address:
  • Phone: 201-921-4687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number22DI020953
License Number StateNJ

VIII. Authorized Official

Name: DR. THOMAS A CHIODO
Title or Position: DOCTOR
Credential: DDS
Phone: 201-921-4687