Provider Demographics
NPI:1205224631
Name:ORAL & MAXILLOFACIAL SURGERY OF QUEENS, LLC
Entity Type:Organization
Organization Name:ORAL & MAXILLOFACIAL SURGERY OF QUEENS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ARIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SADEGHI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:347-579-5159
Mailing Address - Street 1:8201 ROOSEVELT AVENUE, 2ND FLOOR
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372
Mailing Address - Country:US
Mailing Address - Phone:718-844-9903
Mailing Address - Fax:347-436-9569
Practice Address - Street 1:8201 ROOSEVELT AVENUE, 2ND FLOOR
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372
Practice Address - Country:US
Practice Address - Phone:718-844-9903
Practice Address - Fax:347-436-9569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-08
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty