Healthcare Provider Details

I. General information

NPI: 1922278480
Provider Name (Legal Business Name): MOUNTAINVIEW ORAL & MAXILLOFACIAL SURGERY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2008
Last Update Date: 03/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 COLUMBIA DR
JOHNSON CITY NY
13790-3302
US

IV. Provider business mailing address

535 COLUMBIA DR
JOHNSON CITY NY
13790-3302
US

V. Phone/Fax

Practice location:
  • Phone: 607-729-5900
  • Fax:
Mailing address:
  • Phone: 607-729-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number048526-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number230001
License Number StateNY

VIII. Authorized Official

Name: DR. JAMES LEONARD DESANTIS
Title or Position: OWNER
Credential: M.D., DDS
Phone: 607-729-5900