=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225361496
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SANTILLANA FAMILY DENTISTRY L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2009
-----------------------------------------------------
Last Update Date | 04/30/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 LEXINGTON AVE
-----------------------------------------------------
City | PASSAIC
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07055-5260
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-859-0501
-----------------------------------------------------
Fax | 973-859-0503
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 120 LEXINGTON AVE
-----------------------------------------------------
City | PASSAIC
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07055-5260
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-859-0501
-----------------------------------------------------
Fax | 973-859-0503
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MS. MONICA ROLLINS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 973-859-0501
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 22DI02388500
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------