Healthcare Provider Details

I. General information

NPI: 1285880427
Provider Name (Legal Business Name): PARK AVENUE PERIODONTAL PROSTHESIS OBS FACILITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2008
Last Update Date: 08/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

563 PARK AVE
NEW YORK NY
10065-7314
US

IV. Provider business mailing address

563 PARK AVE
NEW YORK NY
10065-7314
US

V. Phone/Fax

Practice location:
  • Phone: 212-838-0090
  • Fax: 212-935-1296
Mailing address:
  • Phone: 212-838-0090
  • Fax: 212-935-1296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: DR. PASQUALE J MALPESO
Title or Position: OWNER
Credential: D.M.D.
Phone: 212-838-0090