Healthcare Provider Details

I. General information

NPI: 1174794275
Provider Name (Legal Business Name): GWEN GIANNINA DDS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2008
Last Update Date: 03/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1173 KENNEDY BLVD
BAYONNE NJ
07002-3132
US

IV. Provider business mailing address

1173 KENNEDY BLVD
BAYONNE NJ
07002-3132
US

V. Phone/Fax

Practice location:
  • Phone: 201-339-1177
  • Fax:
Mailing address:
  • Phone: 201-339-1177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: GWEN GIANNINA
Title or Position: OWNER/ DENTIST
Credential:
Phone: 201-339-1177