Provider Demographics
NPI:1740737758
Name:PARK 62 PERIO & PERIO-PROSTHESIS PC
Entity Type:Organization
Organization Name:PARK 62 PERIO & PERIO-PROSTHESIS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PASQUALE
Authorized Official - Middle Name:
Authorized Official - Last Name:MALPESO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:212-838-0090
Mailing Address - Street 1:563 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-7379
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:563 PARK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-7379
Practice Address - Country:US
Practice Address - Phone:212-838-0090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY440777174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY440777OtherTHE JOINT COMMISSION