Healthcare Provider Details

I. General information

NPI: 1255995502
Provider Name (Legal Business Name): PEDIATRIC DENTISTRY AND ORTHODONTICS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2019
Last Update Date: 04/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 PROSPECT ST STE 1A
MIDLAND PARK NJ
07432-1606
US

IV. Provider business mailing address

6 PROSPECT ST STE 1A
MIDLAND PARK NJ
07432-1606
US

V. Phone/Fax

Practice location:
  • Phone: 201-445-5555
  • Fax: 201-445-5057
Mailing address:
  • Phone: 201-445-5555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: MIKE COLE
Title or Position: VP INSURANCE PLAN MANAGEMENT
Credential:
Phone: 941-955-3150