Provider Demographics
NPI:1043477565
Name:BERGENLINE DENTAL GROUP
Entity Type:Organization
Organization Name:BERGENLINE DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:FUENTES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:201-865-5150
Mailing Address - Street 1:3916 BERGENLINE AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:UNION CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07087-1612
Mailing Address - Country:US
Mailing Address - Phone:201-865-5150
Mailing Address - Fax:201-865-5962
Practice Address - Street 1:3916 BERGENLINE AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:UNION CITY
Practice Address - State:NJ
Practice Address - Zip Code:07087-1612
Practice Address - Country:US
Practice Address - Phone:201-865-5150
Practice Address - Fax:201-865-5962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ229071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0154831Medicaid