Provider Demographics
NPI:1538534854
Name:ORAL SURGERY OF RIVERDALE, P.C.
Entity type:Organization
Organization Name:ORAL SURGERY OF RIVERDALE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HELEN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-472-5252
Mailing Address - Street 1:3333 HENRY HUDSON PKWY
Mailing Address - Street 2:SUITE 9
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-3224
Mailing Address - Country:US
Mailing Address - Phone:718-796-4550
Mailing Address - Fax:718-548-1951
Practice Address - Street 1:3333 HENRY HUDSON PKWY
Practice Address - Street 2:SUITE 9
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-3224
Practice Address - Country:US
Practice Address - Phone:718-796-4550
Practice Address - Fax:718-548-1951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-11
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0535311223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03159991Medicaid