Healthcare Provider Details

I. General information

NPI: 1619378056
Provider Name (Legal Business Name): DR. DIVINA SANTOS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2014
Last Update Date: 09/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38 BELLEVILLE AVE
BLOOMFIELD NJ
07003-5222
US

IV. Provider business mailing address

38 BELLEVILLE AVE
BLOOMFIELD NJ
07003-5222
US

V. Phone/Fax

Practice location:
  • Phone: 973-566-0445
  • Fax: 973-566-0445
Mailing address:
  • Phone: 973-566-0445
  • Fax: 973-566-9397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22DI 02014600
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: