Provider Demographics
NPI:1700923216
Name:VALLEY ORAL & MAXILLOFACIAL SURGERY, PA
Entity Type:Organization
Organization Name:VALLEY ORAL & MAXILLOFACIAL SURGERY, PA
Other - Org Name:VALLEY ORAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VITO
Authorized Official - Middle Name:
Authorized Official - Last Name:MODUGNO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:201-681-0440
Mailing Address - Street 1:370 UNION BLVD
Mailing Address - Street 2:
Mailing Address - City:TOTOWA
Mailing Address - State:NJ
Mailing Address - Zip Code:07512-2561
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:370 UNION BLVD
Practice Address - Street 2:
Practice Address - City:TOTOWA
Practice Address - State:NJ
Practice Address - Zip Code:07512-2561
Practice Address - Country:US
Practice Address - Phone:973-389-1110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2007-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI 180541223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty