Provider Demographics
NPI:1760485247
Name:WILTZ, MAURICIO (DDS)
Entity Type:Individual
Prefix:DR
First Name:MAURICIO
Middle Name:
Last Name:WILTZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 HALSTEAD AVE
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10704-3008
Mailing Address - Country:US
Mailing Address - Phone:914-237-9094
Mailing Address - Fax:718-515-5419
Practice Address - Street 1:3332 ROCHAMBEAU AVENUE
Practice Address - Street 2:DEPARTMENT OF DENTISTRY, 2ND FLOOR
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2836
Practice Address - Country:US
Practice Address - Phone:718-920-4984
Practice Address - Fax:718-515-5419
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0439951223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01763744Medicaid
NYU75067Medicare UPIN
NY01763744Medicaid