Healthcare Provider Details

I. General information

NPI: 1598447328
Provider Name (Legal Business Name): MINT ORAL SURGERY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2023
Last Update Date: 08/02/2023
Certification Date: 08/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4133 WHITE PLAINS RD
BRONX NY
10466-3009
US

IV. Provider business mailing address

4133 WHITE PLAINS RD
BRONX NY
10466-3009
US

V. Phone/Fax

Practice location:
  • Phone: 718-652-3699
  • Fax: 718-374-5475
Mailing address:
  • Phone: 718-652-3699
  • Fax: 718-374-5475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: EDWARD WOODBINE
Title or Position: OWNER
Credential:
Phone: 718-652-3699