Healthcare Provider Details

I. General information

NPI: 1184153181
Provider Name (Legal Business Name): JONATHAN GELLIS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2017
Last Update Date: 08/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 TREMONT AVE
EAST ORANGE NJ
07018
US

IV. Provider business mailing address

789 ROLLING HILL DR
RIVER VALE NJ
07675-6170
US

V. Phone/Fax

Practice location:
  • Phone: 845-548-3841
  • Fax:
Mailing address:
  • Phone: 845-548-3841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number059961
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: