Healthcare Provider Details

I. General information

NPI: 1962847020
Provider Name (Legal Business Name): PREMIER FAMILY DENTAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2013
Last Update Date: 05/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 CLIFTON AVE STE 4 4
CLIFTON NJ
07011-3247
US

IV. Provider business mailing address

520 CLIFTON AVE STE 4 4
CLIFTON NJ
07011-3247
US

V. Phone/Fax

Practice location:
  • Phone: 973-772-4222
  • Fax: 973-772-7652
Mailing address:
  • Phone: 973-772-4222
  • Fax: 973-772-7652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDI0227391
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDI2443200
License Number StateNJ

VIII. Authorized Official

Name: MRS. GIRA RATHOD
Title or Position: OFFICE MANAGER
Credential:
Phone: 973-772-4222