=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740361724
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLIFTON ORAL & MAXILLOFACIAL SURGERY, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1439 BROAD ST
-----------------------------------------------------
City | CLIFTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07013-4221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-778-7171
-----------------------------------------------------
Fax | 973-916-0696
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1439 BROAD ST
-----------------------------------------------------
City | CLIFTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07013-4221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-778-7171
-----------------------------------------------------
Fax | 973-916-0696
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ORAL SURGEON
-----------------------------------------------------
Name | DR. GLENN NICHOLAS GORAB
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 973-778-7171
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------