=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629488267
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WHITESTONE ORAL & MAXILLOFACIAL SURGERY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2014
-----------------------------------------------------
Last Update Date | 05/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 150-43C 14TH AVENUE
-----------------------------------------------------
City | WHITESTONE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-747-7899
-----------------------------------------------------
Fax | 347-436-9569
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 150-43C 14TH AVENUE
-----------------------------------------------------
City | WHITESTONE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-747-7899
-----------------------------------------------------
Fax | 347-436-9569
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SURGEON
-----------------------------------------------------
Name | ARIAN SADEGHI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 347-579-5159
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 053277
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 051861
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------