Provider Demographics
NPI:1578839262
Name:ELITE ORAL & MAXILLOFACIAL SURGERY
Entity Type:Organization
Organization Name:ELITE ORAL & MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ORAL SURGEON
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAHIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GHOBADI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:973-732-4555
Mailing Address - Street 1:246 HAMBURG TPKE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-2156
Mailing Address - Country:US
Mailing Address - Phone:973-732-4555
Mailing Address - Fax:973-732-4556
Practice Address - Street 1:246 HAMBURG TPKE
Practice Address - Street 2:SUITE 304
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-2156
Practice Address - Country:US
Practice Address - Phone:973-732-4555
Practice Address - Fax:973-732-4556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-27
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02332400204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty