Provider Demographics
NPI:1053632281
Name:SOUFANATI, CAROL (DMD)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:
Last Name:SOUFANATI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:CAROL
Other - Middle Name:
Other - Last Name:SOUFANATI-IDROVO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:79 MAY ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07109-1712
Mailing Address - Country:US
Mailing Address - Phone:973-573-0165
Mailing Address - Fax:
Practice Address - Street 1:10 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-3223
Practice Address - Country:US
Practice Address - Phone:973-667-2466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-22
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI024566001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice