Provider Demographics
NPI:1659576643
Name:ANTHONY G & VINCENT DEVINCENTIS
Entity Type:Organization
Organization Name:ANTHONY G & VINCENT DEVINCENTIS
Other - Org Name:BROOKDALE DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:DEVINCENTIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-338-3700
Mailing Address - Street 1:1218 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-3031
Mailing Address - Country:US
Mailing Address - Phone:973-338-3700
Mailing Address - Fax:973-338-7560
Practice Address - Street 1:1218 BROAD ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-3031
Practice Address - Country:US
Practice Address - Phone:973-338-3700
Practice Address - Fax:973-338-7560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-19
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DIO17380001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty