Provider Demographics
NPI:1275793085
Name:INTEGRATED DENTAL AESTETICS
Entity Type:Organization
Organization Name:INTEGRATED DENTAL AESTETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-838-4460
Mailing Address - Street 1:11 KIEL AVE
Mailing Address - Street 2:
Mailing Address - City:KINNELON
Mailing Address - State:NJ
Mailing Address - Zip Code:07405-2549
Mailing Address - Country:US
Mailing Address - Phone:973-838-4460
Mailing Address - Fax:973-838-6258
Practice Address - Street 1:11 KIEL AVE
Practice Address - Street 2:
Practice Address - City:KINNELON
Practice Address - State:NJ
Practice Address - Zip Code:07405-2549
Practice Address - Country:US
Practice Address - Phone:973-838-4460
Practice Address - Fax:973-838-6258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-16
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ10617122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty