Provider Demographics
NPI:1689885345
Name:DR MICHAEL J CISAR, DMD & DR WILLIAM L DERRICKSON, DMD, LLC
Entity Type:Organization
Organization Name:DR MICHAEL J CISAR, DMD & DR WILLIAM L DERRICKSON, DMD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:CISAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-842-6300
Mailing Address - Street 1:709 SYCAMORE AVE
Mailing Address - Street 2:
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-4946
Mailing Address - Country:US
Mailing Address - Phone:732-842-6300
Mailing Address - Fax:732-842-3467
Practice Address - Street 1:709 SYCAMORE AVE
Practice Address - Street 2:
Practice Address - City:TINTON FALLS
Practice Address - State:NJ
Practice Address - Zip Code:07701-4946
Practice Address - Country:US
Practice Address - Phone:732-842-6300
Practice Address - Fax:732-842-3467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI21287122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty