Healthcare Provider Details

I. General information

NPI: 1760485247
Provider Name (Legal Business Name): MAURICIO WILTZ D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 11/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3332 ROCHAMBEAU AVENUE DEPARTMENT OF DENTISTRY, 2ND FLOOR
BRONX NY
10467-2836
US

IV. Provider business mailing address

36 HALSTEAD AVE
YONKERS NY
10704-3008
US

V. Phone/Fax

Practice location:
  • Phone: 718-920-4984
  • Fax: 718-515-5419
Mailing address:
  • Phone: 914-237-9094
  • Fax: 718-515-5419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number043995
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number043995
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: