=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063802627
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ORAL AND IMPLANT SURGERY OF MANHATTAN, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2015
-----------------------------------------------------
Last Update Date | 02/03/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18 E 48TH ST SUITE 1502
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10017-1014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-752-8600
-----------------------------------------------------
Fax | 203-661-0155
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 455 W 23RD ST APT. 17AB
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10011-2148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-752-8600
-----------------------------------------------------
Fax | 203-661-0155
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MEMBER
-----------------------------------------------------
Name | DR. MICHELE SHOSHANA BERGEN
-----------------------------------------------------
Credential | DMD, MD, FACS
-----------------------------------------------------
Telephone | 212-752-8600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 204E00000X
-----------------------------------------------------
Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
-----------------------------------------------------
License Number | 231685
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------