=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205907292
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN F MAKHOUL DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2006
-----------------------------------------------------
Last Update Date | 06/16/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 E RIDGEWOOD AV 2ND FLOOR WEST WING
-----------------------------------------------------
City | RIDGEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-444-9011
-----------------------------------------------------
Fax | 201-857-4676
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1200 E RIDGEWOOD AV 2ND FLOOR WESR WING
-----------------------------------------------------
City | RIDGEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-444-9011
-----------------------------------------------------
Fax | 201-857-4676
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 10652
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------