1447379102 NPI number — NEW JERSEY MOBILE DENTAL PRACTICE, P.A.

Table of content: (NPI 1447379102)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447379102 NPI number — NEW JERSEY MOBILE DENTAL PRACTICE, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEW JERSEY MOBILE DENTAL PRACTICE, P.A.
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:
1447379102
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:
637 WYCKOFF AVE
Provider Second Line Business Mailing Address:
SUITE 236
Provider Business Mailing Address City Name:
WYCKOFF
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07481-1438
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-431-7577
Provider Business Mailing Address Fax Number:
732-431-8070

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24 MERCHANTS WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLTS NECK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07722-1570
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-431-7577
Provider Business Practice Location Address Fax Number:
732-431-8070
Provider Enumeration Date:
03/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BEUKAS
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
732-431-7577

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  DI018346 , 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: 6516301 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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