Healthcare Provider Details

I. General information

NPI: 1982853214
Provider Name (Legal Business Name): FREDRIC CARL MAZZA D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2008
Last Update Date: 02/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 BERGEN ST UH, DEPT OF ORAL AND MAXILLOFACIAL SURGERY, RM C-401
NEWARK NJ
07103-2496
US

IV. Provider business mailing address

67 FOREST DR
POMPTON PLAINS NJ
07444-1516
US

V. Phone/Fax

Practice location:
  • Phone: 973-280-2297
  • Fax:
Mailing address:
  • Phone: 973-280-2297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number22DI02379800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: