Provider Demographics
NPI:1588799803
Name:LINCROFT ORAL AND MAXILLOFACIAL SURGERY
Entity Type:Organization
Organization Name:LINCROFT ORAL AND MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:FRATTELLONE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:732-842-5915
Mailing Address - Street 1:515 NEWMAN SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:LINCROFT
Mailing Address - State:NJ
Mailing Address - Zip Code:07738-1426
Mailing Address - Country:US
Mailing Address - Phone:732-842-5915
Mailing Address - Fax:732-842-5910
Practice Address - Street 1:515 NEWMAN SPRINGS RD
Practice Address - Street 2:
Practice Address - City:LINCROFT
Practice Address - State:NJ
Practice Address - Zip Code:07738-1426
Practice Address - Country:US
Practice Address - Phone:732-842-5915
Practice Address - Fax:732-842-5910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ165141223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6009409Medicaid
NJ6009409Medicaid
NJU45173Medicare UPIN