Healthcare Provider Details

I. General information

NPI: 1598922692
Provider Name (Legal Business Name): WYCKOFF DENTAL ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2008
Last Update Date: 05/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 WYCKOFF AVE
WYCKOFF NJ
07481-1343
US

IV. Provider business mailing address

615 WYCKOFF AVE
WYCKOFF NJ
07481-1343
US

V. Phone/Fax

Practice location:
  • Phone: 201-891-0409
  • Fax: 201-891-0803
Mailing address:
  • Phone: 201-891-0409
  • Fax: 201-891-0803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14867
License Number StateNJ

VIII. Authorized Official

Name: DR. STEVEN ARTHUR MENILLO
Title or Position: OWNER/PARTNER
Credential: DDS
Phone: 201-891-0409