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General NPI Number Information
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NPI Number | 1770779902
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Entity Type | Organization
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Legal Business Name | PEQUANNOCK VALLEY DENTAL ASSOCIATES
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Dates
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Enumeration Date | 09/20/2007
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Last Update Date | 09/20/2007
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Provider Practice Location Address
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Address Line | 567 NEWARK POMPTON TPKE
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City | POMPTON PLAINS
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State | NJ
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Zip | 07444-1737
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Country | US
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Telephone | 973-831-0444
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Fax | 973-831-7770
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Provider Business Mailing Address
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Address Line | 567 NEWARK POMPTON TPKE
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City | POMPTON PLAINS
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State | NJ
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Zip | 07444-1737
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Country | US
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Telephone | 973-831-0444
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Fax | 973-831-7770
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Authorized Official
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Title or Position | OWNER
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Name | DR. BRIAN M MARINO
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Credential | D.M.D
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Telephone | 973-831-0444
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 22DI02208900
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License Number State | NJ
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