Healthcare Provider Details

I. General information

NPI: 1548222466
Provider Name (Legal Business Name): REENA MERLINE VARGHESE-VALLIYIL DMD, MSED, MSC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 02/22/2021
Certification Date: 02/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 ROUTE 73 STE 100
MOUNT LAUREL NJ
08054-5113
US

IV. Provider business mailing address

1120 ROUTE 73 STE 100
MOUNT LAUREL NJ
08054-5113
US

V. Phone/Fax

Practice location:
  • Phone: 856-533-0060
  • Fax:
Mailing address:
  • Phone: 856-533-0060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number22DI02298900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: