=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629286489
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHEN J. LEVINE D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 760 KINDERKAMACK RD
-----------------------------------------------------
City | RIVER EDGE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07661-2447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-261-1522
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 427 KINDERKAMACK RD
-----------------------------------------------------
City | RIVER EDGE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07661-2137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-262-5385
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0700X
-----------------------------------------------------
Taxonomy Name | Prosthodontics
-----------------------------------------------------
License Number | DI007898
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------