Provider Demographics
NPI:1598045379
Name:SALAZAR DENTAL LLC
Entity Type:Organization
Organization Name:SALAZAR DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:JOSE
Authorized Official - Last Name:SALAZAR
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:201-861-1007
Mailing Address - Street 1:6219 BERGENLINE AVE
Mailing Address - Street 2:2ND FL
Mailing Address - City:WEST NEW YORK
Mailing Address - State:NJ
Mailing Address - Zip Code:07093-1605
Mailing Address - Country:US
Mailing Address - Phone:201-861-1007
Mailing Address - Fax:
Practice Address - Street 1:6219 BERGENLINE AVE
Practice Address - Street 2:2ND FL
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093-1605
Practice Address - Country:US
Practice Address - Phone:201-861-1007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-24
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI0241601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0243779Medicaid