Provider Demographics
NPI:1437162807
Name:BERGEN PASSAIC PERIODONTAL GROUP, PA
Entity Type:Organization
Organization Name:BERGEN PASSAIC PERIODONTAL GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:TERENCE
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:201-791-2200
Mailing Address - Street 1:25-15 FAIR LAWN AVE
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-3434
Mailing Address - Country:US
Mailing Address - Phone:201-791-2200
Mailing Address - Fax:201-791-6025
Practice Address - Street 1:25-15 FAIR LAWN AVE
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-3434
Practice Address - Country:US
Practice Address - Phone:201-791-2200
Practice Address - Fax:201-791-6025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJD115851223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty