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General NPI Number Information
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NPI Number | 1891715330
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Entity Type | Organization
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Legal Business Name | ENGLEWOOD DENTAL, PA
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Dates
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Enumeration Date | 07/20/2006
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Last Update Date | 09/13/2012
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Provider Practice Location Address
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Address Line | 370 GRAND AVE SUITE 200
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City | ENGLEWOOD
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State | NJ
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Zip | 07631-4154
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Country | US
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Telephone | 201-871-3555
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Fax | 201-871-9096
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Provider Business Mailing Address
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Address Line | 370 GRAND AVE SUITE 200
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City | ENGLEWOOD
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State | NJ
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Zip | 07631-4154
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Country | US
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Telephone | 201-871-3555
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Fax | 201-871-9096
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JOHN CARLO MINICHETTI
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Credential | DMD
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Telephone | 201-871-3555
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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 | 13552
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License Number State | NJ
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