=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093928038
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WEST MONMOUTH DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 SOUTH MAIN STREET
-----------------------------------------------------
City | ALLENTOWN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-208-0220
-----------------------------------------------------
Fax | 609-208-0990
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 296
-----------------------------------------------------
City | ALLENTOWN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08501-0296
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-208-0220
-----------------------------------------------------
Fax | 609-208-0990
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. SABASTIAN J D'AMICO JR.
-----------------------------------------------------
Credential | D.M.D
-----------------------------------------------------
Telephone | 609-208-0220
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------