Healthcare Provider Details

I. General information

NPI: 1487578480
Provider Name (Legal Business Name): VICTORY 96 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86 VALLEY RD STE 2
MONTCLAIR NJ
07042-2209
US

IV. Provider business mailing address

86 VALLEY RD STE 2
MONTCLAIR NJ
07042-2209
US

V. Phone/Fax

Practice location:
  • Phone: 973-746-1616
  • 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

VIII. Authorized Official

Name: DR. THOMAS ROLLO
Title or Position: OWNER
Credential:
Phone: 862-596-2898