=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962847020
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREMIER FAMILY DENTAL PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2013
-----------------------------------------------------
Last Update Date | 05/02/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 520 CLIFTON AVE STE 4 4
-----------------------------------------------------
City | CLIFTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07011-3247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-772-4222
-----------------------------------------------------
Fax | 973-772-7652
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 520 CLIFTON AVE STE 4 4
-----------------------------------------------------
City | CLIFTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07011-3247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-772-4222
-----------------------------------------------------
Fax | 973-772-7652
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. GIRA RATHOD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 973-772-4222
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | DI2443200
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DI0227391
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------