Provider Demographics
NPI:1083817753
Name:VAN RAALTE, JOAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOAN
Middle Name:
Last Name:VAN RAALTE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 WATCHUNG PLZ
Mailing Address - Street 2:#185
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-4117
Mailing Address - Country:US
Mailing Address - Phone:974-746-5532
Mailing Address - Fax:413-677-0904
Practice Address - Street 1:200 LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:NJ
Practice Address - Zip Code:07506-1943
Practice Address - Country:US
Practice Address - Phone:973-746-5532
Practice Address - Fax:413-677-0904
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI01926304122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist