Provider Demographics
NPI:1538573720
Name:SOUTHERN NEW JERSEY ORAL SURGERY PA
Entity type:Organization
Organization Name:SOUTHERN NEW JERSEY ORAL SURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHARIQ
Authorized Official - Middle Name:AZIZ
Authorized Official - Last Name:VAZIR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:856-428-4445
Mailing Address - Street 1:17 W ORMOND AVE
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08002-3041
Mailing Address - Country:US
Mailing Address - Phone:856-428-4445
Mailing Address - Fax:856-428-4449
Practice Address - Street 1:17 W ORMOND AVE
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08002-3041
Practice Address - Country:US
Practice Address - Phone:856-428-4445
Practice Address - Fax:856-428-4497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-16
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI024902001223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty