Provider Demographics
NPI:1508362583
Name:MAIN STREET DENTAL CARE LLC
Entity Type:Organization
Organization Name:MAIN STREET DENTAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VIVIAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:VILLALOBOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:201-736-2775
Mailing Address - Street 1:6 ORCHARD ST
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:07020-1511
Mailing Address - Country:US
Mailing Address - Phone:201-865-6740
Mailing Address - Fax:
Practice Address - Street 1:7 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:NY
Practice Address - Zip Code:10977-4962
Practice Address - Country:US
Practice Address - Phone:201-865-6740
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-30
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty