Healthcare Provider Details

I. General information

NPI: 1790864908
Provider Name (Legal Business Name): DENTAL GROUP OF WESTFIELD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 ST PAUL STREET
WESTFIELD NJ
07090
US

IV. Provider business mailing address

120 ST PAUL STREET
WESTFIELD NJ
07090
US

V. Phone/Fax

Practice location:
  • Phone: 908-232-6672
  • Fax: 908-232-3998
Mailing address:
  • Phone: 908-232-6672
  • Fax: 908-232-3998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22D100755500
License Number StateNJ

VIII. Authorized Official

Name: DR. JOHN WILEY JR.
Title or Position: CEO
Credential: DDS FAGD
Phone: 908-232-6672