Provider Demographics
NPI:1316597495
Name:PREMIER ORAL SURGERY OF BERGEN COUNTY PC
Entity Type:Organization
Organization Name:PREMIER ORAL SURGERY OF BERGEN COUNTY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:KALLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:201-385-0775
Mailing Address - Street 1:375 S WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BERGENFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07621-4323
Mailing Address - Country:US
Mailing Address - Phone:201-385-0775
Mailing Address - Fax:201-385-5375
Practice Address - Street 1:375 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:BERGENFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07621-4323
Practice Address - Country:US
Practice Address - Phone:201-385-0775
Practice Address - Fax:201-385-5375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJDI15472OtherSTATE DENTAL LICENSE