Healthcare Provider Details

I. General information

NPI: 1366008864
Provider Name (Legal Business Name): MONTCLAIR DENTAL SPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 CLAREMONT AVE
MONTCLAIR NJ
07042-3409
US

IV. Provider business mailing address

204 CLAREMONT AVE
MONTCLAIR NJ
07042-3409
US

V. Phone/Fax

Practice location:
  • Phone: 973-744-1527
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. YOUSEF MOUSSA
Title or Position: OWNER/DENTIST
Credential:
Phone: 973-744-1527