Provider Demographics
NPI:1407989254
Name:CLINTON HILL DENTAL ASSOC
Entity Type:Organization
Organization Name:CLINTON HILL DENTAL ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:973-374-5200
Mailing Address - Street 1:804 CINTON AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07108-1004
Mailing Address - Country:US
Mailing Address - Phone:973-374-5200
Mailing Address - Fax:973-374-5609
Practice Address - Street 1:804 CINTON AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07108-1004
Practice Address - Country:US
Practice Address - Phone:973-374-5200
Practice Address - Fax:973-374-5609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2108128261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3414507Medicaid