Provider Demographics
NPI:1629233358
Name:MANHATTAN MAXILLOFACIAL SURGERY GROUP
Entity Type:Organization
Organization Name:MANHATTAN MAXILLOFACIAL SURGERY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL AND MAXILLOFACIAL SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:L
Authorized Official - Last Name:DEL VALLE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:212-245-5801
Mailing Address - Street 1:45 W 54TH ST
Mailing Address - Street 2:SUITE 1E
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-5404
Mailing Address - Country:US
Mailing Address - Phone:212-245-5801
Mailing Address - Fax:212-977-9486
Practice Address - Street 1:45 W 54TH ST
Practice Address - Street 2:SUITE 1E
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-5404
Practice Address - Country:US
Practice Address - Phone:212-245-5801
Practice Address - Fax:212-977-9486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048825-11223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty