Skip Navigation

Provider Information for 1104049303

Please Note: Issuance of an NPI does not ensure or validate that the Health Care Provider is Licensed or Credentialed. For more information please refer to NPI: What You Need to Know


Gender: MALE

Individual NPI: 1104049303

Calendar   Last Updated:  2011-12-23
  Certification Date: 


Name Value
NPI 1104049303
Enumeration Date 2007-04-10
NPI Type 1 - Individual
Sole Proprietor NO
Status Active
Mailing Address 109 HICKORY HILL BLVD
TOTOWA, NJ 07512-2193
United States

Phone: | Fax:
View Map External Link
Primary Practice Address 529 CLIFTON AVE
CLIFTON, NJ 07011-3229
United States

Phone: 973-777-6363 | Fax: 973-473-4100
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
Primary Taxonomy Selected Taxonomy State License Number
Yes 1223G0001X - Dentist General Practice NJ DI020826