Healthcare Provider Details

I. General information

NPI: 1144578048
Provider Name (Legal Business Name): LINDA DIANE PAULETTE DE LUCA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2012
Last Update Date: 08/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 BROADWAY STE 64
WESTWOOD NJ
07675-1674
US

IV. Provider business mailing address

700 BROADWAY STE 64
WESTWOOD NJ
07675-1674
US

V. Phone/Fax

Practice location:
  • Phone: 201-666-1300
  • Fax: 210-666-2055
Mailing address:
  • Phone: 201-666-1300
  • Fax: 201-666-2055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22D102121900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: