Healthcare Provider Details

I. General information

NPI: 1134385016
Provider Name (Legal Business Name): JANATHA WITHANACHCHI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2008
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 VALLEY ST STE 100
SOUTH ORANGE NJ
07079-2825
US

IV. Provider business mailing address

71 VALLEY ST STE 100
SOUTH ORANGE NJ
07079-2825
US

V. Phone/Fax

Practice location:
  • Phone: 862-250-6952
  • Fax:
Mailing address:
  • Phone: 862-250-6952
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number22DI02398712
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number056508
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: