Healthcare Provider Details

I. General information

NPI: 1578670246
Provider Name (Legal Business Name): MICHAEL PANITCH D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

988 BROAD ST
BLOOMFIELD NJ
07003-2806
US

IV. Provider business mailing address

988 BROAD ST
BLOOMFIELD NJ
07003-2806
US

V. Phone/Fax

Practice location:
  • Phone: 973-338-6667
  • Fax:
Mailing address:
  • Phone: 973-338-6667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22DI0218960
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: