Provider Demographics
NPI:1457417495
Name:ORAL & MAXILLOFACIAL ASSOC OF NUTLEY
Entity Type:Organization
Organization Name:ORAL & MAXILLOFACIAL ASSOC OF NUTLEY
Other - Org Name:ORAL & MAXILLOFACIAL ASSOCCIATES OF NUTLEY, LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:ORAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:M
Authorized Official - Last Name:ECHO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:973-667-5844
Mailing Address - Street 1:187 WASHINGTON AVENUE
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110
Mailing Address - Country:US
Mailing Address - Phone:973-667-5844
Mailing Address - Fax:973-667-6653
Practice Address - Street 1:187 WASHINGTON AVENUE
Practice Address - Street 2:SUITE 1B
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110
Practice Address - Country:US
Practice Address - Phone:973-667-5844
Practice Address - Fax:973-667-6653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJD1016959204E00000X
NJD1017058204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty