Provider Demographics
NPI:1619990520
Name:MINICHETTI, JOHN CARLO (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CARLO
Last Name:MINICHETTI
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 1:370 GRAND AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-4154
Mailing Address - Country:US
Mailing Address - Phone:201-871-3555
Mailing Address - Fax:201-871-9096
Practice Address - Street 1:370 GRAND AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-4154
Practice Address - Country:US
Practice Address - Phone:201-871-3555
Practice Address - Fax:201-871-9096
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ135521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice