Healthcare Provider Details

I. General information

NPI: 1386940096
Provider Name (Legal Business Name): AMERICAN DENTAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2011
Last Update Date: 01/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 WINFIELD SCOTT PLZ
ELIZABETH NJ
07201-2443
US

IV. Provider business mailing address

14 WINFIELD SCOTT PLZ
ELIZABETH NJ
07201-2443
US

V. Phone/Fax

Practice location:
  • Phone: 908-353-5400
  • Fax: 908-353-7273
Mailing address:
  • Phone: 908-353-5400
  • Fax: 908-353-7273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22DI02386200
License Number StateNJ

VIII. Authorized Official

Name: DR. OTHMANE SEDDIKI
Title or Position: OWNER
Credential:
Phone: 908-353-5400