Healthcare Provider Details

I. General information

NPI: 1982602736
Provider Name (Legal Business Name): THOMAS M PANITCH D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date: 03/17/2006
Reactivation Date: 03/23/2006

III. Provider practice location address

20 MYRTLE AVE
IRVINGTON NJ
07111-3310
US

IV. Provider business mailing address

20 MYRTLE AVE
IRVINGTON NJ
07111-3310
US

V. Phone/Fax

Practice location:
  • Phone: 973-374-9752
  • Fax: 973-371-9265
Mailing address:
  • Phone: 973-374-9752
  • Fax: 973-371-9265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7901
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: