Provider Demographics
NPI:1164969325
Name:PARAMUS PARK MALL DENTAL LLC
Entity Type:Organization
Organization Name:PARAMUS PARK MALL DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:IGOR
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:516-798-3444
Mailing Address - Street 1:700 PARAMUS PARK
Mailing Address - Street 2:SUITE 1615
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-3557
Mailing Address - Country:US
Mailing Address - Phone:201-261-3444
Mailing Address - Fax:201-261-3445
Practice Address - Street 1:700 PARAMUS PARK
Practice Address - Street 2:SUITE 1615
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-3557
Practice Address - Country:US
Practice Address - Phone:201-261-3444
Practice Address - Fax:201-261-3445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-26
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI 022429001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty