1104930668 NPI number — COMPREHENSIVE & COSMETIC & GENERAL DISTISTRY

Table of content: (NPI 1104930668)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104930668 NPI number — COMPREHENSIVE & COSMETIC & GENERAL DISTISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMPREHENSIVE & COSMETIC & GENERAL DISTISTRY
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:
1104930668
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/06/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3350 STATE ROUTE 138
Provider Second Line Business Mailing Address:
STE 127
Provider Business Mailing Address City Name:
WALL TOWNSHIP
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07719-9693
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-556-9600
Provider Business Mailing Address Fax Number:
732-556-9601

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3350 STATE ROUTE 138
Provider Second Line Business Practice Location Address:
STE 127
Provider Business Practice Location Address City Name:
WALL TOWNSHIP
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07719-9693
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-556-9600
Provider Business Practice Location Address Fax Number:
732-556-9601
Provider Enumeration Date:
08/19/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MANCINO
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
JOSEPH
Authorized Official Title or Position:
OWNER,PRESIDENT
Authorized Official Telephone Number:
732-556-9600

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  11320 , 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: 11320 . This is a "INS CO'S" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 90730-00-4 . This is a "NJ EMPLOYER ID" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".