=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699275594
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IVY HILL DENTAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2018
-----------------------------------------------------
Last Update Date | 02/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 679 IRVINGTON AVE
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07106-3306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-374-5200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 679 IRVINGTON AVE
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07106-3306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-374-5200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. TONYA X. COOK
-----------------------------------------------------
Credential | DMD, MPH
-----------------------------------------------------
Telephone | 973-374-5200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 22DI02036903
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------