Healthcare Provider Details

I. General information

NPI: 1730165804
Provider Name (Legal Business Name): PAUL A CONDOURIS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

89 GLEN RIDGE AVE
GLEN RIDGE NJ
07028-1413
US

IV. Provider business mailing address

89 GLEN RIDGE AVE
GLEN RIDGE NJ
07028-1413
US

V. Phone/Fax

Practice location:
  • Phone: 973-743-6092
  • Fax: 973-429-3671
Mailing address:
  • Phone: 973-743-6092
  • Fax: 973-429-3671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number11738
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: