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General NPI Number Information
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NPI Number | 1508362583
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Entity Type | Organization
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Legal Business Name | MAIN STREET DENTAL CARE LLC
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Dates
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Enumeration Date | 03/30/2018
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Last Update Date | 03/30/2018
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Provider Practice Location Address
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Address Line | 7 N MAIN ST
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City | SPRING VALLEY
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State | NY
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Zip | 10977-4962
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Country | US
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Telephone | 201-865-6740
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Fax |
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Provider Business Mailing Address
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Address Line | 6 ORCHARD ST
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City | EDGEWATER
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State | NJ
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Zip | 07020-1511
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Country | US
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Telephone | 201-865-6740
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. VIVIAN C VILLALOBOS
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Credential | DDS
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Telephone | 201-736-2775
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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