Provider Demographics
NPI:1326349465
Name:NEW JERSEY MAXILLOFACIAL DIGITAL IMAGING CENTER
Entity Type:Organization
Organization Name:NEW JERSEY MAXILLOFACIAL DIGITAL IMAGING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:OLIVERIE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:732-681-5544
Mailing Address - Street 1:1516 HWY 138
Mailing Address - Street 2:
Mailing Address - City:WALL
Mailing Address - State:NJ
Mailing Address - Zip Code:07719-3700
Mailing Address - Country:US
Mailing Address - Phone:732-681-5544
Mailing Address - Fax:
Practice Address - Street 1:1516 HWY 138
Practice Address - Street 2:
Practice Address - City:WALL
Practice Address - State:NJ
Practice Address - Zip Code:07719-3700
Practice Address - Country:US
Practice Address - Phone:732-681-5544
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-05
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI20496261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology