=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841739588
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. SHAHID AZIZ ORAL AND MAXILLOFACIAL SURGERY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2017
-----------------------------------------------------
Last Update Date | 02/14/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 118 MAPES AVE
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07081-3220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-809-3739
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 118 MAPES AVE
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07081-3220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-809-3739
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. SHAHID RAHIM AZIZ
-----------------------------------------------------
Credential | DMD, MD
-----------------------------------------------------
Telephone | 973-809-3739
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 22DI02188600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------