Provider Demographics
NPI:1952680100
Name:SHORE ORAL AND MAXILLOFACIAL SURGERY, LLC
Entity Type:Organization
Organization Name:SHORE ORAL AND MAXILLOFACIAL SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:KALIKA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:609-748-9600
Mailing Address - Street 1:54 W JIMMIE LEEDS RD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:GALLOWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08205-9438
Mailing Address - Country:US
Mailing Address - Phone:609-748-9600
Mailing Address - Fax:609-748-9611
Practice Address - Street 1:54 W JIMMIE LEEDS RD
Practice Address - Street 2:SUITE 6
Practice Address - City:GALLOWAY
Practice Address - State:NJ
Practice Address - Zip Code:08205-9438
Practice Address - Country:US
Practice Address - Phone:609-748-9600
Practice Address - Fax:609-748-9611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-05
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI022432001223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty