Healthcare Provider Details

I. General information

NPI: 1851516926
Provider Name (Legal Business Name): JOHN ALFRED TALTAVALL III DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 10/17/2022
Certification Date: 10/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 MAIN ST
RIDGEFIELD PARK NJ
07660
US

IV. Provider business mailing address

255 MAIN ST
RIDGEFIELD PARK NJ
07660
US

V. Phone/Fax

Practice location:
  • Phone: 201-440-9190
  • Fax:
Mailing address:
  • Phone: 201-440-9190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22DI01834000
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDI18340
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: