Provider Demographics
NPI:1063690816
Name:GARDEN STATE ORAL SURGERY PA
Entity type:Organization
Organization Name:GARDEN STATE ORAL SURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:N
Authorized Official - Last Name:KALLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:973-335-5252
Mailing Address - Street 1:265 BALDWIN RD
Mailing Address - Street 2:
Mailing Address - City:PARSIPPANY
Mailing Address - State:NJ
Mailing Address - Zip Code:07054-2007
Mailing Address - Country:US
Mailing Address - Phone:973-335-5252
Mailing Address - Fax:
Practice Address - Street 1:265 BALDWIN RD
Practice Address - Street 2:
Practice Address - City:PARSIPPANY
Practice Address - State:NJ
Practice Address - Zip Code:07054-2007
Practice Address - Country:US
Practice Address - Phone:973-335-5252
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-04
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI154721223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU32802Medicare UPIN