Healthcare Provider Details

I. General information

NPI: 1356432173
Provider Name (Legal Business Name): MICHAL R FRUCHTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 12/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 SOUTH PKWY
CLIFTON NJ
07014-1244
US

IV. Provider business mailing address

475 SOUTH PKWY
CLIFTON NJ
07014-1244
US

V. Phone/Fax

Practice location:
  • Phone: 973-249-8107
  • Fax:
Mailing address:
  • Phone: 973-249-8107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22DIO2287300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: