MEDICARE: IMPLANT & DENTAL CENTER OF NJ PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	02028800	NJ

General Provider Information

NPI Number	:	1235540667
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMPLANT & DENTAL CENTER OF NJ PC

Provider Business Mailing Address
First Line	:	18 KEARNY AVE
Second Line	:
City	:	KEARNY
State	:	NJ
Zip	:	07032-2372
Country	:	US
Telephone Number	:	201-868-0808
Fax Number	:	201-955-2651

Provider Business Practice Location Address
First Line	:	6815 BERGENLINE AVE
Second Line	:
City	:	GUTTENBERG
State	:	NJ
Zip	:	07093-1807
Country	:	US
Telephone Number	:	201-868-0808
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DAVID LAC
Credential	:	DDS
Telephone Number	:	201-868-0808

Provider Enumeration Date	:	05/20/2014
Last Update Date	:	05/20/2014

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