Healthcare Provider Details

I. General information

NPI: 1316375454
Provider Name (Legal Business Name): ORAL SURGEONS ON CALL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2013
Last Update Date: 10/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5240 MERRICK RD
MASSAPEQUA NY
11758-6207
US

IV. Provider business mailing address

5240 MERRICK RD
MASSAPEQUA NY
11758-6207
US

V. Phone/Fax

Practice location:
  • Phone: 484-550-6618
  • Fax:
Mailing address:
  • Phone: 484-550-6618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number052799-1
License Number StateNY

VIII. Authorized Official

Name: DR. ANTOINE PANOSSIAN
Title or Position: PRESIDENT
Credential: M.D. D.M.D.
Phone: 484-550-6618