Healthcare Provider Details

I. General information

NPI: 1700923216
Provider Name (Legal Business Name): VALLEY ORAL & MAXILLOFACIAL SURGERY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 08/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 UNION BLVD
TOTOWA NJ
07512-2561
US

IV. Provider business mailing address

370 UNION BLVD
TOTOWA NJ
07512-2561
US

V. Phone/Fax

Practice location:
  • Phone: 973-389-1110
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License NumberDI 18054
License Number StateNJ

VIII. Authorized Official

Name: VITO MODUGNO
Title or Position: OWNER PRESIDENT
Credential: DMD
Phone: 201-681-0440