Healthcare Provider Details

I. General information

NPI: 1205566114
Provider Name (Legal Business Name): 380 DENTAL CARE GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2022
Last Update Date: 06/14/2022
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

380 FAIRFIELD RD
FAIRFIELD NJ
07004-1934
US

IV. Provider business mailing address

380 FAIRFIELD RD
FAIRFIELD NJ
07004-1934
US

V. Phone/Fax

Practice location:
  • Phone: 973-402-0595
  • Fax: 973-808-1177
Mailing address:
  • Phone: 973-402-0595
  • Fax: 973-808-1177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. DEREK LAU
Title or Position: OWNER
Credential: DMD
Phone: 973-402-0595