Healthcare Provider Details

I. General information

NPI: 1700096047
Provider Name (Legal Business Name): JOSEPH D CHIKVASHVILI D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NORTHFIELD AVE
WEST ORANGE NJ
07052-4702
US

IV. Provider business mailing address

100 NORTHFIELD AVE
WEST ORANGE NJ
07052-4702
US

V. Phone/Fax

Practice location:
  • Phone: 973-731-4800
  • Fax: 973-731-1153
Mailing address:
  • Phone: 973-731-4800
  • Fax: 973-731-1153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDI21576
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: