Provider Demographics
NPI:1629287412
Name:CHANTILLY DENTAL GROUP LLC
Entity Type:Organization
Organization Name:CHANTILLY DENTAL GROUP LLC
Other - Org Name:MONMOUTH DENTAL GROUP NORTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:E
Authorized Official - Last Name:TARRAB
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:732-888-7770
Mailing Address - Street 1:1 STATE ROUTE 35
Mailing Address - Street 2:
Mailing Address - City:KEYPORT
Mailing Address - State:NJ
Mailing Address - Zip Code:07735-1128
Mailing Address - Country:US
Mailing Address - Phone:732-888-7770
Mailing Address - Fax:732-888-2711
Practice Address - Street 1:1 STATE ROUTE 35
Practice Address - Street 2:
Practice Address - City:KEYPORT
Practice Address - State:NJ
Practice Address - Zip Code:07735-1128
Practice Address - Country:US
Practice Address - Phone:732-888-7770
Practice Address - Fax:732-888-2711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI01693000122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty