Healthcare Provider Details

I. General information

NPI: 1801049234
Provider Name (Legal Business Name): SIEGFRIED WILLEM TJONAJONG DMD MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2008
Last Update Date: 10/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

947 LINWOOD AVE STE 1 ORAL & MAXILLOFACIAL PROSTHODONTICS
RIDGEWOOD NJ
07450-2939
US

IV. Provider business mailing address

947 LINWOOD AVENUE SUITE 1 NORTH ORAL & MAXILLOFACIAL PROSTHODONTICS
RIDGEWOOD NJ
07450
US

V. Phone/Fax

Practice location:
  • Phone: 201-670-4800
  • Fax: 201-670-6776
Mailing address:
  • Phone: 201-670-4800
  • Fax: 201-670-6776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22DIO1785000
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberNJ-3807
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: