Healthcare Provider Details

I. General information

NPI: 1629233358
Provider Name (Legal Business Name): MANHATTAN MAXILLOFACIAL SURGERY GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2008
Last Update Date: 07/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 W 54TH ST SUITE 1E
NEW YORK NY
10019-5404
US

IV. Provider business mailing address

45 W 54TH ST SUITE 1E
NEW YORK NY
10019-5404
US

V. Phone/Fax

Practice location:
  • Phone: 212-245-5801
  • Fax: 212-977-9486
Mailing address:
  • Phone: 212-245-5801
  • Fax: 212-977-9486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number048825-1
License Number StateNY

VIII. Authorized Official

Name: ANTONIO L DEL VALLE
Title or Position: ORAL AND MAXILLOFACIAL SURGEON
Credential: DMD, MD
Phone: 212-245-5801