Provider Demographics
NPI:1366008864
Name:MONTCLAIR DENTAL SPA
Entity Type:Organization
Organization Name:MONTCLAIR DENTAL SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:YOUSEF
Authorized Official - Middle Name:
Authorized Official - Last Name:MOUSSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-744-1527
Mailing Address - Street 1:204 CLAREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-3409
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:204 CLAREMONT AVE
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-3409
Practice Address - Country:US
Practice Address - Phone:973-744-1527
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-10
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1588703052OtherNPPES