Provider Demographics
NPI:1073671392
Name:KINNELON DENTAL GROUP
Entity Type:Organization
Organization Name:KINNELON DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EMPLOYEE
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:973-838-5585
Mailing Address - Street 1:11 KIEL AVE
Mailing Address - Street 2:
Mailing Address - City:KINNELON
Mailing Address - State:NJ
Mailing Address - Zip Code:07405-2549
Mailing Address - Country:US
Mailing Address - Phone:973-838-5585
Mailing Address - Fax:973-838-6258
Practice Address - Street 1:11 KIEL AVE
Practice Address - Street 2:
Practice Address - City:KINNELON
Practice Address - State:NJ
Practice Address - Zip Code:07405-2549
Practice Address - Country:US
Practice Address - Phone:973-838-5585
Practice Address - Fax:973-838-6258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI02262300122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty