Healthcare Provider Details

I. General information

NPI: 1275463531
Provider Name (Legal Business Name): VENIAMIN KOFANOV DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 CENTRAL AVE
ORANGE NJ
07050-2407
US

IV. Provider business mailing address

325 CENTRAL AVE
ORANGE NJ
07050-2407
US

V. Phone/Fax

Practice location:
  • Phone: 973-676-3700
  • Fax:
Mailing address:
  • Phone: 973-676-3700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22DI03150700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: