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General NPI Number Information
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NPI Number | 1629287412
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Entity Type | Organization
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Legal Business Name | CHANTILLY DENTAL GROUP LLC
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Dates
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Enumeration Date | 05/21/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1 STATE ROUTE 35
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City | KEYPORT
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State | NJ
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Zip | 07735-1128
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Country | US
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Telephone | 732-888-7770
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Fax | 732-888-2711
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Provider Business Mailing Address
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Address Line | 1 STATE ROUTE 35
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City | KEYPORT
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State | NJ
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Zip | 07735-1128
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Country | US
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Telephone | 732-888-7770
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Fax | 732-888-2711
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | DR. DAVID E. TARRAB
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Credential | DDS
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Telephone | 732-888-7770
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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 | DI01693000
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License Number State | NJ
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