# 201 ORAL SURGERY

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1073896809
- **Authorized official:** MRS. SUZANNE WALTKE (OFFICE MANAGER)
- **Authorized official phone:** (201) 767-4001

## Contact information

- **Practice address:** 180 OLD TAPPAN RD, OLD TAPPAN, NJ 07675-7052
- **Practice address phone:** (201) 767-4001
- **Mailing address:** 180 OLD TAPPAN RD, OLD TAPPAN, NJ 07675-7052

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223S0112X | Oral and Maxillofacial Surgery (Dentist) | 22DI01547211 | NJ | — |
| 1223S0112X | Oral and Maxillofacial Surgery (Dentist) | 22DI01805400 | NJ | — |
| 1223S0112X | Oral and Maxillofacial Surgery (Dentist) | 22DI02332400 | NJ | Yes |

## Other

- **Enumeration date:** 09/28/2011
- **Last updated:** 09/28/2011