Provider Demographics
NPI:1235574872
Name:PATERSON DENTAL CLINIC
Entity Type:Organization
Organization Name:PATERSON DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FAIZUL
Authorized Official - Middle Name:T
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:973-684-5854
Mailing Address - Street 1:294 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07501-2030
Mailing Address - Country:US
Mailing Address - Phone:973-684-5854
Mailing Address - Fax:
Practice Address - Street 1:294 BROADWAY
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07501-2030
Practice Address - Country:US
Practice Address - Phone:973-684-5854
Practice Address - Fax:973-684-1952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-09
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI19009122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7093900-01Medicaid