Provider Demographics
NPI:1699833566
Name:SOUTH BERGEN ORAL SURGERY PA
Entity Type:Organization
Organization Name:SOUTH BERGEN ORAL SURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT SO BERGEN ORAL SURGERY PA
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:P
Authorized Official - Last Name:DILASCIO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:201-935-4577
Mailing Address - Street 1:422 STUYVESANT AVE
Mailing Address - Street 2:
Mailing Address - City:LYNDHURST
Mailing Address - State:NJ
Mailing Address - Zip Code:07071
Mailing Address - Country:US
Mailing Address - Phone:201-935-4577
Mailing Address - Fax:201-935-8893
Practice Address - Street 1:422 STUYVESANT AVE
Practice Address - Street 2:
Practice Address - City:LYNDHURST
Practice Address - State:NJ
Practice Address - Zip Code:07071
Practice Address - Country:US
Practice Address - Phone:201-935-4577
Practice Address - Fax:201-935-8893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ92271223S0112X
NJ92181223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
058001OtherMEDICARE PIN
X72996Medicare UPIN