Provider Demographics
NPI:1437591567
Name:MONMOUTH MALL DENTAL, PA
Entity Type:Organization
Organization Name:MONMOUTH MALL DENTAL, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:MIKHAILOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:201-626-2500
Mailing Address - Street 1:180 ROUTE 35 S
Mailing Address - Street 2:
Mailing Address - City:EATONTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07724-2023
Mailing Address - Country:US
Mailing Address - Phone:201-626-2500
Mailing Address - Fax:
Practice Address - Street 1:180 ROUTE 35 S
Practice Address - Street 2:
Practice Address - City:EATONTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07724-2023
Practice Address - Country:US
Practice Address - Phone:201-626-2500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-17
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ197791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty