=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679704431
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALBANY ORAL - MAXILLOFACIAL SURGERY GROUP, LLP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2009
-----------------------------------------------------
Last Update Date | 02/23/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2 EXECUTIVE PARK DR
-----------------------------------------------------
City | ALBANY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12203-3700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-446-1001
-----------------------------------------------------
Fax | 518-446-0802
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2 EXECUTIVE PARK DR
-----------------------------------------------------
City | ALBANY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12203-3700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-446-1001
-----------------------------------------------------
Fax | 518-446-0802
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. LAWRENCE JAMES BUSINO
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 518-446-1001
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------