Healthcare Provider Details

I. General information

NPI: 1992982441
Provider Name (Legal Business Name): NICOLE PADOVAN-LAGRASTA DMD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2008
Last Update Date: 01/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 E UNION AVE
BOUND BROOK NJ
08805-1766
US

IV. Provider business mailing address

105 E UNION AVE
BOUND BROOK NJ
08805-1766
US

V. Phone/Fax

Practice location:
  • Phone: 732-469-4424
  • Fax: 732-469-9138
Mailing address:
  • Phone: 732-469-4424
  • Fax: 732-469-9138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name: DR. NICOLE PADOVAN-LAGRASTA
Title or Position: PRESIDENT
Credential: DMD
Phone: 732-469-4424