MEDICARE: BERGEN ORTHODONTIC ASSOC., PA

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	8033, 2174	NJ

General Provider Information

NPI Number	:	1265655310
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BERGEN ORTHODONTIC ASSOC., PA

Provider Business Mailing Address
First Line	:	500 PIERMONT RD
Second Line	:
City	:	CLOSTER
State	:	NJ
Zip	:	07624-2845
Country	:	US
Telephone Number	:	201-768-4121
Fax Number	:	201-768-3495

Provider Business Practice Location Address
First Line	:	500 PIERMONT RD
Second Line	:
City	:	CLOSTER
State	:	NJ
Zip	:	07624-2845
Country	:	US
Telephone Number	:	201-768-4121
Fax Number	:	201-768-3495

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MARTIN STANLEY LEVITT
Credential	:	D.D.S.
Telephone Number	:	201-768-4121

Provider Enumeration Date	:	04/10/2007
Last Update Date	:	02/27/2008

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