Provider Demographics
NPI:1033296959
Name:FORT LEE ORTHODONTIC ASSOCIATES PC
Entity Type:Organization
Organization Name:FORT LEE ORTHODONTIC ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:ETHAN
Authorized Official - Last Name:GOLUB
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:201-944-9208
Mailing Address - Street 1:2185 LEMOINE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-6036
Mailing Address - Country:US
Mailing Address - Phone:201-944-9208
Mailing Address - Fax:201-944-3630
Practice Address - Street 1:2185 LEMOINE AVE
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-6036
Practice Address - Country:US
Practice Address - Phone:201-944-9208
Practice Address - Fax:201-944-3630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty