Healthcare Provider Details

I. General information

NPI: 1043423767
Provider Name (Legal Business Name): MARLYS PETERSON LEWIS RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 PLAZA RD
FLANDERS NJ
07836-9416
US

IV. Provider business mailing address

77 IRONIA RD
MENDHAM NJ
07945-3141
US

V. Phone/Fax

Practice location:
  • Phone: 973-252-1099
  • Fax:
Mailing address:
  • Phone: 973-543-6287
  • Fax: 973-543-1918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number22HI00149500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: