Healthcare Provider Details

I. General information

NPI: 1942687793
Provider Name (Legal Business Name): PARK SLOPE ORAL & MAXILLOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2015
Last Update Date: 04/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 UNION STREET
BROOKLYN NY
11215
US

IV. Provider business mailing address

805 UNION STREET
BROOKLYN NY
11215
US

V. Phone/Fax

Practice location:
  • Phone: 718-398-1969
  • Fax: 718-398-2792
Mailing address:
  • Phone: 718-398-1969
  • Fax: 718-398-2792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number StateNY

VIII. Authorized Official

Name: MRS. ANIUSKA T GUTIERREZ
Title or Position: MANAGER
Credential:
Phone: 718-398-1969