=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700335239
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TENAFLY DENTAL SPA PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2016
-----------------------------------------------------
Last Update Date | 09/26/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2 DEAN DR 3RD FLOOR
-----------------------------------------------------
City | TENAFLY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07670-2765
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-668-0662
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 464 NEVADA ST
-----------------------------------------------------
City | PARAMUS
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07652-5622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-668-0662
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JULIA IGDALEV
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 201-668-0662
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 22DI02013400
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------