Provider Demographics
NPI:1043225451
Name:MOUNTAIN LAKES DENTAL ASSOCIATES, PA
Entity Type:Organization
Organization Name:MOUNTAIN LAKES DENTAL ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:KIN
Authorized Official - Last Name:ENG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:973-328-7199
Mailing Address - Street 1:3125 STATE ROUTE 10
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:DENVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07834-3493
Mailing Address - Country:US
Mailing Address - Phone:973-328-7199
Mailing Address - Fax:973-328-7122
Practice Address - Street 1:3125 STATE ROUTE 10
Practice Address - Street 2:SUITE 1B
Practice Address - City:DENVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07834-3493
Practice Address - Country:US
Practice Address - Phone:973-328-7199
Practice Address - Fax:973-328-7122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI017580001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty