Healthcare Provider Details

I. General information

NPI: 1235421496
Provider Name (Legal Business Name): LASTING IMPRESSIONS DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2011
Last Update Date: 05/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 CEDAR LN SUITE U-1
TEANECK NJ
07666-4316
US

IV. Provider business mailing address

185 CEDAR LN SUITE U-1
TEANECK NJ
07666-4316
US

V. Phone/Fax

Practice location:
  • Phone: 201-836-4335
  • Fax: 201-836-5920
Mailing address:
  • Phone: 201-836-4335
  • Fax: 201-836-5920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number22D101805200
License Number StateNJ

VIII. Authorized Official

Name: DR. TIMOTHY SAVAGE
Title or Position: GENERAL DENTIST
Credential: DMD
Phone: 201-836-4335