MEDICARE: THEODORE A. OSHETSKY D.M.D.

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	1223G0001X	General Practice Dentistry	22DI01409700	NJ

General Provider Information

NPI Number	:	1871653113
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THEODORE A. OSHETSKY D.M.D.

Provider Business Mailing Address
First Line	:	6 MAPLE PL
Second Line	:
City	:	OCEANPORT
State	:	NJ
Zip	:	07757-1625
Country	:	US
Telephone Number	:	732-263-1282
Fax Number	:

Provider Business Practice Location Address
First Line	:	60 STATE ROUTE 36
Second Line	:	STE B2
City	:	WEST LONG BRANCH
State	:	NJ
Zip	:	07764-1428
Country	:	US
Telephone Number	:	732-229-5004
Fax Number	:	732-229-0599

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/09/2006
Last Update Date	:	07/08/2007

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