1639283948 NPI number — SUBURBAN PERIODONTICS AND IMPLANTS LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639283948 NPI number — SUBURBAN PERIODONTICS AND IMPLANTS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUBURBAN PERIODONTICS AND IMPLANTS 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:
1639283948
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
75 MAIN STREET
Provider Second Line Business Mailing Address:
SUITE 107
Provider Business Mailing Address City Name:
MILLBURN
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07041
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-467-5567
Provider Business Mailing Address Fax Number:
973-467-5639

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75 MAIN STREET
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
MILLBURN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07041
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-467-5567
Provider Business Practice Location Address Fax Number:
973-467-5639
Provider Enumeration Date:
08/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GOREN ROBINS
Authorized Official First Name:
CHERYL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
973-467-5567

Provider Taxonomy Codes

  • Taxonomy code: 1223P0300X , with the licence number:  TIN , 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)





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