1174223572 NPI number — MONTCLAIR ORTHODONTICS, LLC

Table of content: (NPI 1174223572)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174223572 NPI number — MONTCLAIR ORTHODONTICS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MONTCLAIR ORTHODONTICS, 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:
1174223572
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
218 LORRAINE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UPPER MONTCLAIR
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07043-1915
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-744-1912
Provider Business Mailing Address Fax Number:
973-744-5955

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
218 LORRAINE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UPPER MONTCLAIR
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07043-1915
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-744-1912
Provider Business Practice Location Address Fax Number:
973-744-5955
Provider Enumeration Date:
03/06/2023

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RUBINO
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
CHRISTOPHER
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
973-744-1912

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1396930855 . This is a "NPPES" identifier . This identifiers is of the category "OTHER".
  • Identifier: 22DI02349400 . This is a "NJ STATE BOARD OF DENTISTRY" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 1134251606 . This is a "NPPES" identifier . This identifiers is of the category "OTHER".
  • Identifier: 22DI01426800 . This is a "NJ STATE BOARD OF DENTISTRY" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".