=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942385216
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID KALLUS DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 335 MAPLE ST
-----------------------------------------------------
City | ENGLEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07631-3705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-952-0220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 335 MAPLE ST
-----------------------------------------------------
City | ENGLEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07631-3705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-952-0220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | DI02158600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 051143
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------