Healthcare Provider Details

I. General information

NPI: 1992125926
Provider Name (Legal Business Name): MICHAEL J BIXBY DMD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2014
Last Update Date: 04/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 MAPLE AVE
RED BANK NJ
07701-1731
US

IV. Provider business mailing address

250 MAPLE AVE
RED BANK NJ
07701-1731
US

V. Phone/Fax

Practice location:
  • Phone: 732-224-1160
  • Fax:
Mailing address:
  • Phone: 732-224-1160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22DI02038600
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL BIXBY
Title or Position: OWNER
Credential: DMD
Phone: 732-859-4974