Healthcare Provider Details

I. General information

NPI: 1770801086
Provider Name (Legal Business Name): MONA LISA COSMETIC SURGERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2010
Last Update Date: 05/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1176 HAMBURG TPKE
WAYNE NJ
07470-5069
US

IV. Provider business mailing address

1176 HAMBURG TPKE
WAYNE NJ
07470-5069
US

V. Phone/Fax

Practice location:
  • Phone: 973-692-9300
  • Fax: 973-692-9301
Mailing address:
  • Phone: 973-692-9300
  • Fax: 973-692-9301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberMA065731
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberMA065731
License Number StateNJ

VIII. Authorized Official

Name: RAMTIN KASSIR
Title or Position: PHYSICIAN
Credential: M.D., F.A.C.S.
Phone: 973-692-9300