Provider Demographics
NPI:1518988088
Name:DEROBERTIS, NICHOLAS C (DMD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:C
Last Name:DEROBERTIS
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 1:354 OLD HOOK RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:WESTWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07675-3246
Mailing Address - Country:US
Mailing Address - Phone:201-666-2125
Mailing Address - Fax:201-666-9576
Practice Address - Street 1:354 OLD HOOK RD
Practice Address - Street 2:SUITE 202
Practice Address - City:WESTWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07675-3246
Practice Address - Country:US
Practice Address - Phone:201-666-2125
Practice Address - Fax:201-666-9576
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ160711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice