Healthcare Provider Details

I. General information

NPI: 1174059679
Provider Name (Legal Business Name): SOUREN HAJJAR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2017
Last Update Date: 07/11/2024
Certification Date: 07/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 BERGEN ST ROOM B854
NEWARK NJ
07101-1709
US

IV. Provider business mailing address

110 BERGEN ST RM B-854
NEWARK NJ
07103-2495
US

V. Phone/Fax

Practice location:
  • Phone: 973-972-3126
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberDN29069
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN29069
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: