Provider Demographics
NPI:1184861114
Name:PASSAIC DENTAL ASSOCIATION
Entity Type:Organization
Organization Name:PASSAIC DENTAL ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-778-7272
Mailing Address - Street 1:244 PAULISON AVE
Mailing Address - Street 2:
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055-3806
Mailing Address - Country:US
Mailing Address - Phone:973-778-7272
Mailing Address - Fax:973-778-5755
Practice Address - Street 1:244 PAULISON AVE
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-3806
Practice Address - Country:US
Practice Address - Phone:973-778-7272
Practice Address - Fax:973-778-5755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-13
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI020935001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0180041Medicaid