MEDICARE: AESTHETIC ORAL & MAXILLOFACIAL SURGERY LLC

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	261QS0112X	Oral and Maxillofacial Surgery Clinic/Center	22DI020953	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1770587230	OTHER	NJ	INDIVIDUAL NPI DR. CHIODO

General Provider Information

NPI Number	:	1770781411
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AESTHETIC ORAL & MAXILLOFACIAL SURGERY LLC

Provider Business Mailing Address
First Line	:	52 INDEPENDENCE WAY
Second Line	:
City	:	JERSEY CITY
State	:	NJ
Zip	:	07305-5460
Country	:	US
Telephone Number	:	201-921-4687
Fax Number	:

Provider Business Practice Location Address
First Line	:	348 E MAIN ST
Second Line	:
City	:	SOMERVILLE
State	:	NJ
Zip	:	08876-3110
Country	:	US
Telephone Number	:	908-722-0850
Fax Number	:

Authorized Official
Title or Position	:	DOCTOR
Name	:	DR. THOMAS A CHIODO
Credential	:	DDS
Telephone Number	:	201-921-4687

Provider Enumeration Date	:	07/03/2007
Last Update Date	:	10/22/2007

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