Provider Demographics
NPI:1457656381
Name:PARK AVENUE MAXILLARY & MANDIBULAR RESTORATION PC
Entity Type:Organization
Organization Name:PARK AVENUE MAXILLARY & MANDIBULAR RESTORATION PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PONCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-838-0090
Mailing Address - Street 1:563 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-7379
Mailing Address - Country:US
Mailing Address - Phone:212-838-0090
Mailing Address - Fax:212-935-1296
Practice Address - Street 1:563 PARK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-7379
Practice Address - Country:US
Practice Address - Phone:212-838-0090
Practice Address - Fax:212-935-1296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0386071261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical