Provider Demographics
NPI:1033378575
Name:BERGEN DENTAL PRACTICE, P.C.
Entity Type:Organization
Organization Name:BERGEN DENTAL PRACTICE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMED
Authorized Official - Middle Name:MANSOORUL
Authorized Official - Last Name:IMAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:201-385-0013
Mailing Address - Street 1:21 MAGNOLIA ST
Mailing Address - Street 2:
Mailing Address - City:BERGENFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07621-3812
Mailing Address - Country:US
Mailing Address - Phone:201-385-0013
Mailing Address - Fax:201-385-0842
Practice Address - Street 1:21 MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:BERGENFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07621-3812
Practice Address - Country:US
Practice Address - Phone:201-385-0013
Practice Address - Fax:201-385-0842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ208951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty