Provider Demographics
NPI:1417017146
Name:ENGLEWOOD DENTAL, PA
Entity Type:Organization
Organization Name:ENGLEWOOD DENTAL, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MINICHETTI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:201-871-3555
Mailing Address - Street 1:370 GRAND AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-4154
Mailing Address - Country:US
Mailing Address - Phone:201-871-3555
Mailing Address - Fax:201-871-9096
Practice Address - Street 1:370 GRAND AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-4154
Practice Address - Country:US
Practice Address - Phone:201-871-3555
Practice Address - Fax:201-871-9096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI018935001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty