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General NPI Number Information
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NPI Number | 1053921643
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Entity Type | Organization
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Legal Business Name | UPPER WEST SIDE ORAL & MAXILLOFACIAL SURGERY
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Dates
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Enumeration Date | 08/07/2020
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Last Update Date | 08/07/2020
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Provider Practice Location Address
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Address Line | 140 W 69TH ST PH 1G
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City | NEW YORK
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State | NY
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Zip | 10023-5173
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Country | US
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Telephone | 646-734-6742
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Fax |
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Provider Business Mailing Address
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Address Line | 140 W 69TH ST PH 1G
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City | NEW YORK
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State | NY
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Zip | 10023-5173
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DDS, MD
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Name | NAM PARK
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Credential | DDS, MD
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Telephone | 646-734-6742
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number |
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License Number State |
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