Healthcare Provider Details

I. General information

NPI: 1932165578
Provider Name (Legal Business Name): SALLY-JO PLACA DMD, MPA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

432 AVENEL ST
AVENEL NJ
07001-1150
US

IV. Provider business mailing address

432 AVENEL ST
AVENEL NJ
07001-1150
US

V. Phone/Fax

Practice location:
  • Phone: 732-634-4797
  • Fax: 732-634-6109
Mailing address:
  • Phone: 732-634-4797
  • Fax: 732-634-6109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDI17088
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: