Healthcare Provider Details

I. General information

NPI: 1184615015
Provider Name (Legal Business Name): CORNELIUS LEON DYSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 BELVIDERE AVE
WASHINGTON NJ
07882-1417
US

IV. Provider business mailing address

134 BELVIDERE AVE
WASHINGTON NJ
07882-1417
US

V. Phone/Fax

Practice location:
  • Phone: 908-835-3500
  • Fax: 908-835-8846
Mailing address:
  • Phone: 908-835-3500
  • Fax: 908-835-8846

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDI217130
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: