Provider Demographics
NPI:1558856815
Name:GHISALBERTI, GIANCARLO LUCIANO (DMD)
Entity Type:Individual
Prefix:DR
First Name:GIANCARLO
Middle Name:LUCIANO
Last Name:GHISALBERTI
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 1:758 BERGEN BLVD
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07657-1406
Mailing Address - Country:US
Mailing Address - Phone:201-424-5599
Mailing Address - Fax:
Practice Address - Street 1:7918 KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-4120
Practice Address - Country:US
Practice Address - Phone:201-854-1616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-28
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI027269001223G0001X
NJ22DR03255122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice