Provider Demographics
NPI:1740591064
Name:VC ORAL AND MAXILLOFACIAL SURGERY
Entity Type:Organization
Organization Name:VC ORAL AND MAXILLOFACIAL SURGERY
Other - Org Name:PALISADES ORAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CAPUTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-585-8282
Mailing Address - Street 1:1530 PALISADE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-5471
Mailing Address - Country:US
Mailing Address - Phone:201-585-8082
Mailing Address - Fax:201-585-0805
Practice Address - Street 1:1530 PALISADE AVE
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-5471
Practice Address - Country:US
Practice Address - Phone:201-585-8082
Practice Address - Fax:201-585-0805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-01
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI20747261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU76631Medicare UPIN