Provider Demographics
NPI:1619221827
Name:NEW JERSEY CENTER FOR ORAL & MAXILLOFACIAL SURGERY
Entity Type:Organization
Organization Name:NEW JERSEY CENTER FOR ORAL & MAXILLOFACIAL SURGERY
Other - Org Name:COSA/COSTELLO ORAL SURGERY ASSOCIATES, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:201-712-5556
Mailing Address - Street 1:949 SPRING VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07607-1452
Mailing Address - Country:US
Mailing Address - Phone:201-712-5556
Mailing Address - Fax:201-712-9190
Practice Address - Street 1:949 SPRING VALLEY RD
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07607-1452
Practice Address - Country:US
Practice Address - Phone:201-712-5556
Practice Address - Fax:201-712-9190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-09
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI198471223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty