Healthcare Provider Details

I. General information

NPI: 1518434935
Provider Name (Legal Business Name): ORTHIQUE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2018
Last Update Date: 10/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1124 E JERSEY ST
ELIZABETH NJ
07201-2406
US

IV. Provider business mailing address

1124 E JERSEY ST
ELIZABETH NJ
07201-2406
US

V. Phone/Fax

Practice location:
  • Phone: 973-472-4900
  • Fax:
Mailing address:
  • Phone: 973-472-4900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL ETHAN SKOLNICK
Title or Position: OWNER
Credential:
Phone: 973-472-4900