Provider Demographics
NPI:1104249226
Name:GARDEN STATE ORAL & MAXILLOFACIAL SURGERY, LLC
Entity type:Organization
Organization Name:GARDEN STATE ORAL & MAXILLOFACIAL SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STUART
Authorized Official - Middle Name:
Authorized Official - Last Name:KATZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:201-794-3344
Mailing Address - Street 1:1 BROADWAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ELMWOOD PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07407-1842
Mailing Address - Country:US
Mailing Address - Phone:201-794-3344
Mailing Address - Fax:201-794-0454
Practice Address - Street 1:1 BROADWAY
Practice Address - Street 2:SUITE 101
Practice Address - City:ELMWOOD PARK
Practice Address - State:NJ
Practice Address - Zip Code:07407-1842
Practice Address - Country:US
Practice Address - Phone:201-794-3344
Practice Address - Fax:201-794-0454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-24
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI218701223S0112X
NJDI158471223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU28119Medicare UPIN