=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497363071
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BERGEN PREMIERE DENTISTRY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2020
-----------------------------------------------------
Last Update Date | 07/20/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 245 E MAIN ST
-----------------------------------------------------
City | RAMSEY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07446-1942
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-746-4614
-----------------------------------------------------
Fax | 862-377-6111
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 245 E MAIN ST
-----------------------------------------------------
City | RAMSEY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07446-1942
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-746-4614
-----------------------------------------------------
Fax | 862-377-6111
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | EWA CIECIEREGA
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 973-699-0808
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------