Provider Demographics
NPI:1598151060
Name:PISANO, PETER JR
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:
Last Name:PISANO
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 CRESCENT CT
Mailing Address - Street 2:
Mailing Address - City:MORGANVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07751-2068
Mailing Address - Country:US
Mailing Address - Phone:917-939-3038
Mailing Address - Fax:
Practice Address - Street 1:49 BRANCH AVE
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-2203
Practice Address - Country:US
Practice Address - Phone:732-741-2042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-12
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI0273151223X0400X
NY0603171223X0400X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics