Provider Demographics
NPI:1073915369
Name:ORAL AND MAXILLOFACIAL SURGERY AND IMPLANT SPECIALISTS OF MIDDLESEX
Entity Type:Organization
Organization Name:ORAL AND MAXILLOFACIAL SURGERY AND IMPLANT SPECIALISTS OF MIDDLESEX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:GOULSTON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:908-222-0040
Mailing Address - Street 1:295 DURHAM AVE
Mailing Address - Street 2:SUITE 213
Mailing Address - City:SOUTH PLAINFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07080-2548
Mailing Address - Country:US
Mailing Address - Phone:908-222-0040
Mailing Address - Fax:908-222-0041
Practice Address - Street 1:295 DURHAM AVE
Practice Address - Street 2:SUITE 213
Practice Address - City:SOUTH PLAINFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07080-2548
Practice Address - Country:US
Practice Address - Phone:908-222-0040
Practice Address - Fax:908-222-0041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-18
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02509200261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery