Healthcare Provider Details

I. General information

NPI: 1083576235
Provider Name (Legal Business Name): VITA DAVYDOV
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2025
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 HUDSON ST STE 201
HOBOKEN NJ
07030-5640
US

IV. Provider business mailing address

79 HUDSON ST STE 201
HOBOKEN NJ
07030-5640
US

V. Phone/Fax

Practice location:
  • Phone: 551-900-6202
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22DI03117600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: