Healthcare Provider Details

I. General information

NPI: 1336249739
Provider Name (Legal Business Name): ORAL SURGERY, MT. SINAI SCHOOL OF MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 GUSTAVE L. LEVY PLACE, BOX 1187
NEW YORK NY
11209
US

IV. Provider business mailing address

1 GUSTAVE L. LEVY PLACE, BOX 1187
NEW YORK NY
11209
US

V. Phone/Fax

Practice location:
  • Phone: 212-241-0300
  • Fax: 212-996-9793
Mailing address:
  • Phone: 212-241-0300
  • Fax: 212-996-9793

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: KATHALEEN GRANT
Title or Position: ADMINISTRATIVE DIRECTOR
Credential: MHSA
Phone: 212-241-0806