Healthcare Provider Details

I. General information

NPI: 1235150335
Provider Name (Legal Business Name): JACK LEGON DMD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 PARK PL
NEWTON NJ
07860-1747
US

IV. Provider business mailing address

40 PARK PL
NEWTON NJ
07860-1747
US

V. Phone/Fax

Practice location:
  • Phone: 973-383-5700
  • Fax: 973-383-4131
Mailing address:
  • Phone: 973-383-5700
  • Fax: 973-383-4131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number10842
License Number StateNJ

VIII. Authorized Official

Name: DR. JACK LEGON
Title or Position: DENTIST/OWNER
Credential: D.M.D.
Phone: 973-383-5700