Healthcare Provider Details

I. General information

NPI: 1427995018
Provider Name (Legal Business Name): DYLAN ROBERT THEISS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2026
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ROBERT WOOD JOHNSON PL # 08901
NEW BRUNSWICK NJ
08901-1928
US

IV. Provider business mailing address

185 CEDAR AVE
HACKENSACK NJ
07601-2953
US

V. Phone/Fax

Practice location:
  • Phone: 201-218-5137
  • Fax:
Mailing address:
  • Phone: 201-218-5137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number25MT00326100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: