=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154086254
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENTAL WELLNESS OF CLIFTON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2021
-----------------------------------------------------
Last Update Date | 11/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1149 BLOOMFIELD AVE STE A
-----------------------------------------------------
City | CLIFTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07012-2314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-473-2410
-----------------------------------------------------
Fax | 973-473-4552
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1149 BLOOMFIELD AVE STE A
-----------------------------------------------------
City | CLIFTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07012-2314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | RADA MEYTIN
-----------------------------------------------------
Credential | DMS
-----------------------------------------------------
Telephone | 973-473-2410
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------