Provider Demographics
NPI:1346445947
Name:POCONO ORAL SURGERY
Entity Type:Organization
Organization Name:POCONO ORAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:POLITO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-343-7529
Mailing Address - Street 1:451 EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940
Mailing Address - Country:US
Mailing Address - Phone:845-343-7529
Mailing Address - Fax:845-343-7532
Practice Address - Street 1:451 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940
Practice Address - Country:US
Practice Address - Phone:845-343-7529
Practice Address - Fax:845-343-7532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-15
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044627-11223P0106X
NY045048-11223P0106X
NY0511651223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty