1386055333 NPI number — DIAMOND BRACES DOVER

Table of content: (NPI 1386055333)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386055333 NPI number — DIAMOND BRACES DOVER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIAMOND BRACES DOVER
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:
1386055333
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/13/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 ENGLE ST
Provider Second Line Business Mailing Address:
SUITE #303
Provider Business Mailing Address City Name:
ENGLEWOOD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07631-2936
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-308-8181
Provider Business Mailing Address Fax Number:
718-373-6799

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
66 E MCFARLAN ST
Provider Second Line Business Practice Location Address:
3RD FLOOR
Provider Business Practice Location Address City Name:
DOVER
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07801-3533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-366-2244
Provider Business Practice Location Address Fax Number:
718-373-6799
Provider Enumeration Date:
05/13/2014

Additional Information

Authorized Official

Authorized Official Last Name:
DRUT
Authorized Official First Name:
OLEG
Authorized Official Middle Name:
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
973-366-2244

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  22DI2070700 , 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: 8072701 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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