Provider Demographics
NPI:1427382563
Name:EASTSIDE ORAL SURGERY
Entity Type:Organization
Organization Name:EASTSIDE ORAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:S
Authorized Official - Last Name:BRISMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:212-348-0020
Mailing Address - Street 1:231 E 106TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-4005
Mailing Address - Country:US
Mailing Address - Phone:212-348-0020
Mailing Address - Fax:646-219-2039
Practice Address - Street 1:231 E 106TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-4005
Practice Address - Country:US
Practice Address - Phone:212-348-0020
Practice Address - Fax:646-219-2039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-22
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0472591223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02249521Medicaid