Healthcare Provider Details

I. General information

NPI: 1679003255
Provider Name (Legal Business Name): MSC ORAL SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2017
Last Update Date: 06/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1468 MADISON AVENUE ANNENBERG BUILDING 2ND FLOOR
NEW YORK NY
10029
US

IV. Provider business mailing address

19 PINE LN
CORTLANDT MANOR NY
10567-5903
US

V. Phone/Fax

Practice location:
  • Phone: 920-312-1833
  • Fax:
Mailing address:
  • Phone: 920-312-1833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MATTHEW CLARK
Title or Position: OWNER
Credential: DDS, MD
Phone: 920-312-1833