Provider Demographics
NPI:1780992958
Name:BETHEL ORAL SURGERY LLC
Entity type:Organization
Organization Name:BETHEL ORAL SURGERY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:201-969-8888
Mailing Address - Street 1:1319 ANDERSON AVE
Mailing Address - Street 2:SUITE #D
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-1770
Mailing Address - Country:US
Mailing Address - Phone:201-969-8888
Mailing Address - Fax:
Practice Address - Street 1:1319 ANDERSON AVE
Practice Address - Street 2:SUITE #D
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-1770
Practice Address - Country:US
Practice Address - Phone:201-969-8888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-21
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ206181223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty