Healthcare Provider Details

I. General information

NPI: 1427819895
Provider Name (Legal Business Name): WYCKOFF DENTAL SPA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2024
Last Update Date: 01/22/2024
Certification Date: 01/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

541 CEDAR HILL AVE
WYCKOFF NJ
07481-2150
US

IV. Provider business mailing address

541 CEDAR HILL AVE
WYCKOFF NJ
07481-2150
US

V. Phone/Fax

Practice location:
  • Phone: 201-444-2383
  • Fax:
Mailing address:
  • Phone: 201-444-2383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LUIS E MARTINEZ
Title or Position: DIRECTOR OF REVENUE CYCLE
Credential:
Phone: 732-801-9176