=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437576733
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRESTIGE ORAL SURGERY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2014
-----------------------------------------------------
Last Update Date | 03/25/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3700 ROUTE 27 SUITE 103
-----------------------------------------------------
City | PRINCETON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08540-9610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-297-7000
-----------------------------------------------------
Fax | 732-297-3638
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3700 ROUTE 27 SUITE 103
-----------------------------------------------------
City | PRINCETON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08540-9610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-297-7000
-----------------------------------------------------
Fax | 732-297-3638
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MOHAMMED S ERAKAT
-----------------------------------------------------
Credential | DMD, MD
-----------------------------------------------------
Telephone | 571-228-4139
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 22DI0233870
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------