Healthcare Provider Details

I. General information

NPI: 1588998405
Provider Name (Legal Business Name): NEW YORK AVENUE DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2009
Last Update Date: 09/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3703 NEW YORK AVE
UNION CITY NJ
07087-4807
US

IV. Provider business mailing address

3703 NEW YORK AVE
UNION CITY NJ
07087-4807
US

V. Phone/Fax

Practice location:
  • Phone: 201-305-8800
  • Fax: 201-305-8900
Mailing address:
  • Phone: 201-305-8800
  • Fax: 201-305-8900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number19152
License Number StateNJ

VIII. Authorized Official

Name: DR. FADI I BEYDOUN
Title or Position: PRESIDENT
Credential: D.M.D
Phone: 201-305-8800