1093152746 NPI number — VERONA-CEDAR GROVE DENTAL ASSOCIATES

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 1093152746 NPI number — VERONA-CEDAR GROVE DENTAL ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VERONA-CEDAR GROVE DENTAL ASSOCIATES
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:
1093152746
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/03/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
756 POMPTON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CEDAR GROVE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07009-1229
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-239-6969
Provider Business Mailing Address Fax Number:
973-239-6295

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
756 POMPTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CEDAR GROVE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07009-1229
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-239-6969
Provider Business Practice Location Address Fax Number:
973-239-6295
Provider Enumeration Date:
06/03/2013

Additional Information

Authorized Official

Authorized Official Last Name:
MADSEN
Authorized Official First Name:
WAYNE
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
973-239-6969

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  22DI01698800 , 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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