Provider Demographics
NPI:1275781890
Name:DENTAL PROFESSIONALS OF FAIR LAWN PA
Entity Type:Organization
Organization Name:DENTAL PROFESSIONALS OF FAIR LAWN PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JODY
Authorized Official - Middle Name:Z
Authorized Official - Last Name:BARDASH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:201-797-1555
Mailing Address - Street 1:10-06 SADDLE RIVER RD
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-5732
Mailing Address - Country:US
Mailing Address - Phone:201-797-1555
Mailing Address - Fax:201-797-1558
Practice Address - Street 1:10-06 SADDLE RIVER RD
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-5732
Practice Address - Country:US
Practice Address - Phone:201-797-1555
Practice Address - Fax:201-797-1558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-08
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI00918500122300000X
NJ22DI016947001223G0001X
NJ22DI023400001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
7572810001Medicare NSC