Provider Demographics
NPI:1396061891
Name:PARK AVENUE ORAL & FACIAL SURGERY, P.C.
Entity type:Organization
Organization Name:PARK AVENUE ORAL & FACIAL SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RUBEN
Authorized Official - Middle Name:
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:212-988-6725
Mailing Address - Street 1:970 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-0324
Mailing Address - Country:US
Mailing Address - Phone:212-988-6725
Mailing Address - Fax:212-988-6726
Practice Address - Street 1:970 PARK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-0324
Practice Address - Country:US
Practice Address - Phone:212-988-6725
Practice Address - Fax:212-988-6726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-09
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0536551223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02922883Medicaid
NY6499990001Medicare NSC