Provider Demographics
NPI:1154860120
Name:PROUSI ORAL & FACIAL SURGERY, LLC
Entity Type:Organization
Organization Name:PROUSI ORAL & FACIAL SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:PROUSI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:609-526-8650
Mailing Address - Street 1:1900 MOUNT HOLLY RD
Mailing Address - Street 2:BUILDING 500
Mailing Address - City:BURLINGTON TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08016-4722
Mailing Address - Country:US
Mailing Address - Phone:609-526-8650
Mailing Address - Fax:609-526-8640
Practice Address - Street 1:1900 MOUNT HOLLY RD
Practice Address - Street 2:BUILDING 500
Practice Address - City:BURLINGTON TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08016-4722
Practice Address - Country:US
Practice Address - Phone:609-526-8650
Practice Address - Fax:609-526-8640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-23
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI025416001223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty