Provider Demographics
NPI:1558831438
Name:AGN DENTAL PRACTICES, PC
Entity Type:Organization
Organization Name:AGN DENTAL PRACTICES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ADMASU
Authorized Official - Middle Name:N
Authorized Official - Last Name:GIZACHEW
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:347-455-1108
Mailing Address - Street 1:16 RIVERSIDE LN
Mailing Address - Street 2:
Mailing Address - City:HOLMDEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07733-2084
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:178 HIGHWAY 35
Practice Address - Street 2:
Practice Address - City:EATONTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07724-1883
Practice Address - Country:US
Practice Address - Phone:732-475-7535
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AGN DENTAL PRACTICES, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-12-04
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0440833Medicaid