1023479359 NPI number — ADVANCED DENTAL ANESTHESIA SERVICES

Table of content: (NPI 1023479359)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023479359 NPI number — ADVANCED DENTAL ANESTHESIA SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED DENTAL ANESTHESIA SERVICES
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:
1023479359
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
48 BI STATE PLZ # 268
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OLD TAPPAN
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07675-7003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-660-7464
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 ROUTE 303
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
TAPPAN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10983-2133
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-848-2255
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/15/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MENDIA
Authorized Official First Name:
ROSALIE
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
201-660-7464

Provider Taxonomy Codes

  • Taxonomy code: 1223D0004X , with the licence number:  D102532800 , 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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