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General NPI Number Information
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NPI Number | 1942425137
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Entity Type | Organization
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Legal Business Name | LOUIS J RUSSO JR JONATHAN L NICOZISIS DMD MS PA
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Dates
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Enumeration Date | 04/15/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 601 EWING ST B 12
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City | PRINCETON
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State | NJ
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Zip | 08540-2757
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Country | US
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Telephone | 609-924-3271
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Fax |
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Provider Business Mailing Address
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Address Line | 601 EWING ST B 12
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City | PRINCETON
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State | NJ
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Zip | 08540-2757
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Country | US
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Telephone | 609-924-3271
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Fax |
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Authorized Official
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Title or Position | PARTNER, OWNER
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Name | DR. JONATHAN LOUIS NICOZISIS
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Credential | DMD MS
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Telephone | 609-924-3271
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | DI 20775
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License Number State | NJ
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