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General NPI Number Information
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NPI Number | 1235540667
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Entity Type | Organization
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Legal Business Name | IMPLANT & DENTAL CENTER OF NJ PC
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Dates
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Enumeration Date | 05/20/2014
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Last Update Date | 05/20/2014
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Provider Practice Location Address
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Address Line | 6815 BERGENLINE AVE
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City | GUTTENBERG
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State | NJ
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Zip | 07093-1807
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Country | US
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Telephone | 201-868-0808
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Fax |
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Provider Business Mailing Address
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Address Line | 18 KEARNY AVE
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City | KEARNY
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State | NJ
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Zip | 07032-2372
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Country | US
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Telephone | 201-868-0808
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Fax | 201-955-2651
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Authorized Official
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Title or Position | OWNER
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Name | DR. DAVID LAC
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Credential | DDS
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Telephone | 201-868-0808
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 02028800
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License Number State | NJ
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