Healthcare Provider Details

I. General information

NPI: 1205586831
Provider Name (Legal Business Name): PHILIP TYLER BACIGALUPO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2022
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 NEWTON SPARTA RD
NEWTON NJ
07860-2811
US

IV. Provider business mailing address

61 NEWTON SPARTA RD
NEWTON NJ
07860-2811
US

V. Phone/Fax

Practice location:
  • Phone: 973-383-7200
  • Fax:
Mailing address:
  • Phone: 973-383-7200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22DI02963300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: