Healthcare Provider Details

I. General information

NPI: 1487935391
Provider Name (Legal Business Name): ORAL AND MAXILLOFACIAL SURGERY OF QUEENS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2011
Last Update Date: 09/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3775 103RD ST
CORONA NY
11368-1979
US

IV. Provider business mailing address

3775 103RD ST
CORONA NY
11368-1979
US

V. Phone/Fax

Practice location:
  • Phone: 718-565-5005
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number051861
License Number StateNY

VIII. Authorized Official

Name: DR. ARIAN SADEGHI
Title or Position: MANAGER
Credential:
Phone: 718-565-5005