1225197361 NPI number — NORTH BERGEN FAMILY DENTAL CARE LLC

Table of content: (NPI 1225197361)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225197361 NPI number — NORTH BERGEN FAMILY DENTAL CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTH BERGEN FAMILY DENTAL CARE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225197361
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7821 BERGENLINE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH BERGEN
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07047-4942
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-869-0030
Provider Business Mailing Address Fax Number:
201-869-0020

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7821 BERGENLINE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH BERGEN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07047-4942
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-869-0030
Provider Business Practice Location Address Fax Number:
201-869-0020
Provider Enumeration Date:
12/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GUNTUNUR
Authorized Official First Name:
MANORAMA
Authorized Official Middle Name:
Authorized Official Title or Position:
GENERAL DENTIST
Authorized Official Telephone Number:
201-869-0030

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  DI20520 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1086983 . This is a "HORIZON HEALTH CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 985772 . This is a "UNITED CONCORDIA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 016386 . This is a "AMERIGROUP" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 30536 . This is a "AETNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 20520 . This is a "DELTA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 7794509 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 223354 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".




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