=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306165303
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ATLANTIC FAMILY DENTISTRY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2010
-----------------------------------------------------
Last Update Date | 05/31/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 180 WASHINGTON AVE FL 2
-----------------------------------------------------
City | BELLEVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07109-2541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-450-4400
-----------------------------------------------------
Fax | 973-450-4401
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 180 WASHINGTON AVE FL 2
-----------------------------------------------------
City | BELLEVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07109-2541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-450-4400
-----------------------------------------------------
Fax | 973-450-4401
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER/OWNER
-----------------------------------------------------
Name | DR. FERNANDO TORDOYA
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 973-450-4400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 22DI02292200
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------