Healthcare Provider Details

I. General information

NPI: 1659588283
Provider Name (Legal Business Name): KONSTANTIN MALTSEN D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

189 FRANKLIN AVE
NUTLEY NJ
07110-3823
US

IV. Provider business mailing address

189 FRANKLIN AVE
NUTLEY NJ
07110-3823
US

V. Phone/Fax

Practice location:
  • Phone: 973-661-1020
  • Fax: 973-661-1012
Mailing address:
  • Phone: 973-661-1020
  • Fax: 973-661-1012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDI22757
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: