MEDICARE: NOVA PEDIATRIC DENTISTRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1205488780
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NOVA PEDIATRIC DENTISTRY

Provider Business Mailing Address
First Line	:	1172A 14TH ST
Second Line	:
City	:	FORT LEE
State	:	NJ
Zip	:	07024-1658
Country	:	US
Telephone Number	:	917-902-7407
Fax Number	:

Provider Business Practice Location Address
First Line	:	316 KNICKERBOCKER RD
Second Line	:
City	:	DUMONT
State	:	NJ
Zip	:	07628-1724
Country	:	US
Telephone Number	:	201-384-4500
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. BRIAN NO
Credential	:	DDS
Telephone Number	:	917-902-7407

Provider Enumeration Date	:	07/15/2019
Last Update Date	:	07/15/2019

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Directions to “NOVA PEDIATRIC DENTISTRY ” Practice Location

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