Provider Demographics
NPI:1770749426
Name:WARREN ORAL & MAXILLOFACIAL SURGERY CENTER, LLC
Entity type:Organization
Organization Name:WARREN ORAL & MAXILLOFACIAL SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL SURGEON/ PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:908-222-7922
Mailing Address - Street 1:31 MOUNTAIN BLVD BLDG T
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:NJ
Mailing Address - Zip Code:07059-5648
Mailing Address - Country:US
Mailing Address - Phone:908-222-7922
Mailing Address - Fax:908-222-7923
Practice Address - Street 1:31 MOUNTAIN BLVD BLDG T
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:NJ
Practice Address - Zip Code:07059-5648
Practice Address - Country:US
Practice Address - Phone:908-222-7922
Practice Address - Fax:908-222-7923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-01
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ020367001223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty