Provider Demographics
NPI:1922278480
Name:MOUNTAINVIEW ORAL & MAXILLOFACIAL SURGERY, P.C.
Entity Type:Organization
Organization Name:MOUNTAINVIEW ORAL & MAXILLOFACIAL SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:LEONARD
Authorized Official - Last Name:DESANTIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD, DDS
Authorized Official - Phone:607-729-5900
Mailing Address - Street 1:535 COLUMBIA DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-3302
Mailing Address - Country:US
Mailing Address - Phone:607-729-5900
Mailing Address - Fax:
Practice Address - Street 1:535 COLUMBIA DR
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-3302
Practice Address - Country:US
Practice Address - Phone:607-729-5900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048526-11223S0112X
NY230001174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02395297Medicaid
NY02395297Medicaid