Healthcare Provider Details

I. General information

NPI: 1245499847
Provider Name (Legal Business Name): HERAWATI T KANDOU DDS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2008
Last Update Date: 06/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

163 WASHINGTON VALLEY RD STE 106 WASHINGTON VALLEY OFFICE PARK
WARREN NJ
07059-7181
US

IV. Provider business mailing address

163 WASHINGTON VALLEY RD STE 106 WASHINGTON VALLEY OFFICE PARK
WARREN NJ
07059-7181
US

V. Phone/Fax

Practice location:
  • Phone: 732-560-5988
  • Fax: 732-563-6999
Mailing address:
  • Phone: 732-560-5988
  • Fax: 732-563-6999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number9708
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number3026
License Number StateNJ

VIII. Authorized Official

Name: DR. HERAWATI T KANDOU
Title or Position: PRESIDENT ORTHODONTIST
Credential: DDS
Phone: 732-560-5988