Healthcare Provider Details

I. General information

NPI: 1912011230
Provider Name (Legal Business Name): COLONIA DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

422 FAIRVIEW AVE
COLONIA NJ
07067-3717
US

IV. Provider business mailing address

422 FAIRVIEW AVE
COLONIA NJ
07067-3717
US

V. Phone/Fax

Practice location:
  • Phone: 732-381-7171
  • Fax: 732-499-7958
Mailing address:
  • Phone: 732-381-7171
  • Fax: 732-499-7958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22DI012965
License Number StateNJ

VIII. Authorized Official

Name: DR. STEVEN JAMES CENNAMO
Title or Position: SEC/TREAS.
Credential: D.D.S.
Phone: 732-381-7171