Provider Demographics
NPI:1114203387
Name:21ST AVE DENTAL LLC
Entity Type:Organization
Organization Name:21ST AVE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:E
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:973-742-1991
Mailing Address - Street 1:318 21ST AVE
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07501-3538
Mailing Address - Country:US
Mailing Address - Phone:973-742-1991
Mailing Address - Fax:
Practice Address - Street 1:318 21ST AVE
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07501-3538
Practice Address - Country:US
Practice Address - Phone:973-742-1991
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ14409122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty