Provider Demographics
NPI:1477175388
Name:GENCO, JOHN THOMAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:THOMAS
Last Name:GENCO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 CHELSEA AVE APT 308
Mailing Address - Street 2:
Mailing Address - City:LONG BRANCH
Mailing Address - State:NJ
Mailing Address - Zip Code:07740-8165
Mailing Address - Country:US
Mailing Address - Phone:732-557-1323
Mailing Address - Fax:
Practice Address - Street 1:362 RIDGEWAY ST
Practice Address - Street 2:
Practice Address - City:MOUNT HOLLY
Practice Address - State:NJ
Practice Address - Zip Code:08060-1447
Practice Address - Country:US
Practice Address - Phone:609-267-3230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-13
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ390200000X
NJ22D1028340001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program