Provider Demographics
NPI:1235540667
Name:IMPLANT & DENTAL CENTER OF NJ PC
Entity Type:Organization
Organization Name:IMPLANT & DENTAL CENTER OF NJ PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:LAC
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:201-868-0808
Mailing Address - Street 1:18 KEARNY AVE
Mailing Address - Street 2:
Mailing Address - City:KEARNY
Mailing Address - State:NJ
Mailing Address - Zip Code:07032-2372
Mailing Address - Country:US
Mailing Address - Phone:201-868-0808
Mailing Address - Fax:201-955-2651
Practice Address - Street 1:6815 BERGENLINE AVE
Practice Address - Street 2:
Practice Address - City:GUTTENBERG
Practice Address - State:NJ
Practice Address - Zip Code:07093-1807
Practice Address - Country:US
Practice Address - Phone:201-868-0808
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-20
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ020288001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty