Provider Demographics
NPI:1194845610
Name:AVERSA, JOHN EDWARD (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:EDWARD
Last Name:AVERSA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 E PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:WALDWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:07463-2009
Mailing Address - Country:US
Mailing Address - Phone:201-652-5499
Mailing Address - Fax:201-652-2479
Practice Address - Street 1:39 E PROSPECT ST
Practice Address - Street 2:
Practice Address - City:WALDWICK
Practice Address - State:NJ
Practice Address - Zip Code:07463-2009
Practice Address - Country:US
Practice Address - Phone:201-652-5499
Practice Address - Fax:201-652-2479
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI015744001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice