Provider Demographics
NPI:1598447328
Name:MINT ORAL SURGERY PLLC
Entity Type:Organization
Organization Name:MINT ORAL SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODBINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-652-3699
Mailing Address - Street 1:4133 WHITE PLAINS RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10466-3009
Mailing Address - Country:US
Mailing Address - Phone:718-652-3699
Mailing Address - Fax:718-374-5475
Practice Address - Street 1:4133 WHITE PLAINS RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-3009
Practice Address - Country:US
Practice Address - Phone:718-652-3699
Practice Address - Fax:718-374-5475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-02
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial SurgeryGroup - Single Specialty