Healthcare Provider Details

I. General information

NPI: 1326677204
Provider Name (Legal Business Name): BENJAMIN DYLAN GOLUB
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2020
Last Update Date: 01/12/2024
Certification Date: 01/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 BLUEBERRY DR
WOODCLIFF LAKE NJ
07677-8106
US

IV. Provider business mailing address

50 BLUEBERRY DRIVE
WOODCLIFF LAKE NJ
07677
US

V. Phone/Fax

Practice location:
  • Phone: 201-543-9741
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22DIO2894100
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22DIO2894101
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: