Healthcare Provider Details

I. General information

NPI: 1316597495
Provider Name (Legal Business Name): PREMIER ORAL SURGERY OF BERGEN COUNTY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2019
Last Update Date: 09/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 S WASHINGTON AVE
BERGENFIELD NJ
07621-4323
US

IV. Provider business mailing address

375 S WASHINGTON AVE
BERGENFIELD NJ
07621-4323
US

V. Phone/Fax

Practice location:
  • Phone: 201-385-0775
  • Fax: 201-385-5375
Mailing address:
  • Phone: 201-385-0775
  • Fax: 201-385-5375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN KALLIS
Title or Position: OWNER
Credential: DMD
Phone: 201-385-0775