1700365129 NPI number — MONDOVI DENTAL OF NEW JERSEY - BEJARANO PC

Table of content: (NPI 1700365129)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700365129 NPI number — MONDOVI DENTAL OF NEW JERSEY - BEJARANO PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MONDOVI DENTAL OF NEW JERSEY - BEJARANO PC
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:
1700365129
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/07/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 90
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONDOVI
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54755-0090
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-598-2311
Provider Business Mailing Address Fax Number:
715-350-6855

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
513 BOULEVARD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENILWORTH
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07033-1637
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
908-276-6652
Provider Business Practice Location Address Fax Number:
908-709-4337
Provider Enumeration Date:
08/07/2018

Additional Information

Authorized Official

Authorized Official Last Name:
BRION-MARTIN
Authorized Official First Name:
DIANE
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
CREDENTIALING SUPERVISOR
Authorized Official Telephone Number:
715-598-2311

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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