Healthcare Provider Details

I. General information

NPI: 1144043092
Provider Name (Legal Business Name): PROFESSIONAL ORAL SURGERY ALLIANCE OF DOWNSTATE NEW YORK PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2024
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 CENTRAL PARK AVE STE 207
SCARSDALE NY
10583-3250
US

IV. Provider business mailing address

125 ENTERPRISE DR STE 200
PITTSBURGH PA
15275-1223
US

V. Phone/Fax

Practice location:
  • Phone: 914-472-5252
  • Fax:
Mailing address:
  • Phone:
  • 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: KAYLA GRAHAM
Title or Position: CREDENTIALING
Credential:
Phone: 724-698-2474