Provider Demographics
NPI:1487635967
Name:TOWER PLAZA DENTISTRY PC
Entity Type:Organization
Organization Name:TOWER PLAZA DENTISTRY PC
Other - Org Name:LENA KHAYLOMSKY DMD
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LENA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAYLOMSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:201-348-1616
Mailing Address - Street 1:4100 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:WEEHAWKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07086
Mailing Address - Country:US
Mailing Address - Phone:201-348-1616
Mailing Address - Fax:201-348-4877
Practice Address - Street 1:4100 PARK AVE
Practice Address - Street 2:
Practice Address - City:WEEHAWKEN
Practice Address - State:NJ
Practice Address - Zip Code:07086
Practice Address - Country:US
Practice Address - Phone:201-348-1616
Practice Address - Fax:201-348-4877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22424122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0038792Medicaid