Healthcare Provider Details

I. General information

NPI: 1871114512
Provider Name (Legal Business Name): MARIGOLD PEDIATRIC DENTISTRY AND ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2020
Last Update Date: 01/11/2024
Certification Date: 01/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1713 SPRINGFIELD AVE
MAPLEWOOD NJ
07040-2914
US

IV. Provider business mailing address

180 OLD TAPPAN RD STE 1A
OLD TAPPAN NJ
07675-7052
US

V. Phone/Fax

Practice location:
  • Phone: 973-821-7161
  • Fax:
Mailing address:
  • Phone: 973-821-7161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. ELENA CICIOLLA
Title or Position: OWNER
Credential: DMD
Phone: 954-691-7906