MEDICARE: MARISSA HALUM DMD

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	1223P0221X	Pediatric Dentistry	22DI02306000	NJ

General Provider Information

NPI Number	:	1841318078
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARISSA HALUM DMD

Provider Business Mailing Address
First Line	:	151 KENSINGTON AVE
Second Line	:
City	:	JERSEY CITY
State	:	NJ
Zip	:	07304-1805
Country	:	US
Telephone Number	:	201-434-3070
Fax Number	:	732-356-0038

Provider Business Practice Location Address
First Line	:	111 E UNION AVE
Second Line	:
City	:	BOUND BROOK
State	:	NJ
Zip	:	08805-1713
Country	:	US
Telephone Number	:	732-356-1830
Fax Number	:	732-356-0038

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/26/2007
Last Update Date	:	07/08/2007

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