Healthcare Provider Details

I. General information

NPI: 1073681060
Provider Name (Legal Business Name): GREGORY VANVLIETDDS,PETER PERERA DMD,PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 SICOMAC RD
NORTH HALEDON NJ
07508-2971
US

IV. Provider business mailing address

33 SICOMAC RD
NORTH HALEDON NJ
07508-2971
US

V. Phone/Fax

Practice location:
  • Phone: 973-427-0300
  • Fax: 973-427-7745
Mailing address:
  • Phone: 973-427-0300
  • Fax: 973-427-7745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22DI01271000
License Number StateNJ

VIII. Authorized Official

Name: DR. GREGORY VANVLIET
Title or Position: OWNER
Credential: D.D.S.
Phone: 973-427-0300