MEDICARE: MADISON AVENUE ORAL SURGERY AND IMPLANT CENTER, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	047288	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700179124
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MADISON AVENUE ORAL SURGERY AND IMPLANT CENTER, PC

Provider Business Mailing Address
First Line	:	295 MADISON AVE FL 28
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10017-6351
Country	:	US
Telephone Number	:	212-660-0305
Fax Number	:	718-284-5600

Provider Business Practice Location Address
First Line	:	295 MADISON AVE FL 28
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10017-6351
Country	:	US
Telephone Number	:	212-660-0305
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MOSES DATSON
Credential	:	DDS
Telephone Number	:	212-660-0305

Provider Enumeration Date	:	05/18/2011
Last Update Date	:	07/09/2024

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